Provider Demographics
NPI:1861163156
Name:RUIZ FERNANDEZ, LEYDIANA
Entity type:Individual
Prefix:
First Name:LEYDIANA
Middle Name:
Last Name:RUIZ FERNANDEZ
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 1:9950 SW 8TH ST APT 112
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2842
Mailing Address - Country:US
Mailing Address - Phone:786-656-7717
Mailing Address - Fax:
Practice Address - Street 1:9950 SW 8TH ST APT 112
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-2842
Practice Address - Country:US
Practice Address - Phone:786-656-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-117853106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106769500Medicaid