Healthcare Provider Details

I. General information

NPI: 1376296665
Provider Name (Legal Business Name): RYAN NICHOLAS PETRECCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 DOVE ST STE 150
NEWPORT BEACH CA
92660-2837
US

IV. Provider business mailing address

12912 BROOKHURST ST STE 480
GARDEN GROVE CA
92840-4867
US

V. Phone/Fax

Practice location:
  • Phone: 949-630-8290
  • Fax:
Mailing address:
  • Phone: 714-636-6286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: