Healthcare Provider Details

I. General information

NPI: 1285860718
Provider Name (Legal Business Name): MR. RYAN JOSEPH GRUMICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 PRESSLEY ST
SANTA ROSA CA
95404-5526
US

IV. Provider business mailing address

2170 KAWANA TER
SANTA ROSA CA
95404-6331
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-6955
  • Fax: 707-543-8176
Mailing address:
  • Phone: 707-799-2439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: