Healthcare Provider Details

I. General information

NPI: 1265044168
Provider Name (Legal Business Name): PENINSULA COUNSELING AND CONSULTING INC RYAN GARDNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3099 TELEGRAPH AVE
BERKELEY CA
94705-2035
US

IV. Provider business mailing address

1259 EL CAMINO REAL # 136
MENLO PARK CA
94025-4208
US

V. Phone/Fax

Practice location:
  • Phone: 650-644-4454
  • Fax: 650-644-4456
Mailing address:
  • Phone: 650-644-4454
  • Fax: 650-644-4456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: RYAN GARDNER
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA, LCSW
Phone: 510-778-4494