Provider Demographics
NPI:1760162754
Name:WALL, RYAN G
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:G
Last Name:WALL
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 1:10 ORANGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95965-3314
Mailing Address - Country:US
Mailing Address - Phone:530-965-2906
Mailing Address - Fax:
Practice Address - Street 1:10 ORANGEWOOD WAY
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95965-3314
Practice Address - Country:US
Practice Address - Phone:530-965-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)