Provider Demographics
NPI:1174189831
Name:RYCKMAN, KSENIA
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:RYCKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MOORPARK AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2680
Mailing Address - Country:US
Mailing Address - Phone:408-975-2730
Mailing Address - Fax:
Practice Address - Street 1:1080 N 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4425
Practice Address - Country:US
Practice Address - Phone:408-869-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health