Provider Demographics
NPI:1861150310
Name:RUIZ, GRACE KELLY
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:KELLY
Last Name:RUIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6788
Mailing Address - Country:US
Mailing Address - Phone:626-267-4191
Mailing Address - Fax:
Practice Address - Street 1:129 OLIVE AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6788
Practice Address - Country:US
Practice Address - Phone:626-267-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty