Provider Demographics
NPI:1821509654
Name:THOM, RYAN C (MFTI)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:THOM
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5178 CONNECTICUT DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-3937
Mailing Address - Country:US
Mailing Address - Phone:805-657-5099
Mailing Address - Fax:
Practice Address - Street 1:2751 NAPA VALLEY CORPORATE DR
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6216
Practice Address - Country:US
Practice Address - Phone:707-227-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAIMF101526101YM0800X
CA127134106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty