Provider Demographics
NPI:1932635463
Name:WATANABE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WATANABE
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 1:197 WINDY LN
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-6529
Mailing Address - Country:US
Mailing Address - Phone:949-297-6072
Mailing Address - Fax:
Practice Address - Street 1:23181 LA CADENA DR
Practice Address - Street 2:SUITE 103
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1479
Practice Address - Country:US
Practice Address - Phone:949-297-6072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96220106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist