=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265044168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENINSULA COUNSELING AND CONSULTING INC RYAN GARDNER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2020
-----------------------------------------------------
Last Update Date | 08/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3099 TELEGRAPH AVE
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94705-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-644-4454
-----------------------------------------------------
Fax | 650-644-4456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1259 EL CAMINO REAL # 136
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-644-4454
-----------------------------------------------------
Fax | 650-644-4456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | RYAN GARDNER
-----------------------------------------------------
Credential | MBA, LCSW
-----------------------------------------------------
Telephone | 510-778-4494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------