=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396528196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN EDWARD BRINK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2023
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 CAMINO DEL RIO S STE 201
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-346-4020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 CAMINO DEL RIO S STE 201
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-346-4020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 18108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------