Basic Information
| Provider Information | |||||||||
| NPI: | 1174189831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYCKMAN | ||||||||
| FirstName: | KSENIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 MOORPARK AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089752730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1080 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951124425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088699160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2019 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.