Basic Information
| Provider Information | |||||||||
| NPI: | 1942475983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FROELICH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FROELICH | ||||||||
| OtherFirstName: | RYAN | ||||||||
| OtherMiddleName: | CHARLES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4000 W METROPOLITAN DR #401 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4000 W METROPOLITAN DR # 401 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 21758 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | LCS29462 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1942475983 | 05 | CA | MEDICAID |