Provider Demographics
NPI:1194213983
Name:GOGARTY, RYAN JAMES
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:GOGARTY
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 1:62 SILVER PINE LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4535
Mailing Address - Country:US
Mailing Address - Phone:925-216-2797
Mailing Address - Fax:
Practice Address - Street 1:3478 BUSKIRK AVE STE 260
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4358
Practice Address - Country:US
Practice Address - Phone:925-943-1794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-09-11
Deactivation Date:2018-05-25
Deactivation Code:
Reactivation Date:2018-06-05
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA108521390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty