Healthcare Provider Details

I. General information

NPI: 1003171984
Provider Name (Legal Business Name): RYAN THOMAS NEACE MA, LPC, NCC, CCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2012
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14650 DEERWOOD ST
POWAY CA
92064-6457
US

IV. Provider business mailing address

14650 DEERWOOD ST
POWAY CA
92064-6457
US

V. Phone/Fax

Practice location:
  • Phone: 858-227-7719
  • Fax: 866-596-5017
Mailing address:
  • Phone: 314-879-4255
  • Fax: 866-596-5017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701005000
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2013014281
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: