Healthcare Provider Details

I. General information

NPI: 1720922032
Provider Name (Legal Business Name): RYAN CARROLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 GOUGH ST
SAN FRANCISCO CA
94102-5945
US

IV. Provider business mailing address

32 ANSON WAY
KENSINGTON CA
94707-1105
US

V. Phone/Fax

Practice location:
  • Phone: 415-917-1292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16569
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number145631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: