MEDICARE: BRYAN VAN RAVENHORST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	105285	CA

General Provider Information

NPI Number	:	1609545284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN VAN RAVENHORST

Provider Business Mailing Address
First Line	:	PO BOX 26813
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93729-6813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1141 W SHAW AVE STE 203
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-3713
Country	:	US
Telephone Number	:	559-428-3137
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2021
Last Update Date	:	08/24/2023

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