Provider Demographics
NPI:1366874802
Name:ROBERTS, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15340 UPPER ELLEN RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95033-8283
Mailing Address - Country:US
Mailing Address - Phone:408-410-5456
Mailing Address - Fax:
Practice Address - Street 1:15340 UPPER ELLEN RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95033-8283
Practice Address - Country:US
Practice Address - Phone:408-410-5456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool