Healthcare Provider Details

I. General information

NPI: 1659192136
Provider Name (Legal Business Name): RYAN MCVICAR KOZISEK AMFT
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 G ST STE 4
ARCATA CA
95521-6247
US

IV. Provider business mailing address

PO BOX 22665
OAKLAND CA
94609-5265
US

V. Phone/Fax

Practice location:
  • Phone: 707-502-2083
  • Fax: 707-388-1896
Mailing address:
  • Phone: 707-502-2487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number145310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: