Provider Demographics
NPI:1376296665
Name:PETRECCA, RYAN NICHOLAS
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:NICHOLAS
Last Name:PETRECCA
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 1:12912 BROOKHURST ST STE 480
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4867
Mailing Address - Country:US
Mailing Address - Phone:714-636-6286
Mailing Address - Fax:
Practice Address - Street 1:1151 DOVE ST STE 150
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2837
Practice Address - Country:US
Practice Address - Phone:949-630-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician