Healthcare Provider Details

I. General information

NPI: 1174189831
Provider Name (Legal Business Name): KSENIA RYCKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 N 7TH ST
SAN JOSE CA
95112-4425
US

IV. Provider business mailing address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

V. Phone/Fax

Practice location:
  • Phone: 408-869-9160
  • Fax:
Mailing address:
  • Phone: 408-975-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: