Basic Information
| Provider Information | |||||||||
| NPI: | 1285860718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUMICH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 ALBANY DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954013608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077992439 | ||||||||
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| Practice Location | |||||||||
| Address1: | 634 PRESSLEY ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954045526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075736955 | ||||||||
| FaxNumber: | 7075438176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 3456 | 01 | CA | MEDICAL | OTHER |