Provider Demographics
NPI:1659192136
Name:KOZISEK, RYAN MCVICAR (AMFT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MCVICAR
Last Name:KOZISEK
Suffix:
Gender:X
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22665
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-5265
Mailing Address - Country:US
Mailing Address - Phone:707-502-2487
Mailing Address - Fax:
Practice Address - Street 1:822 G ST STE 4
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6247
Practice Address - Country:US
Practice Address - Phone:707-502-2083
Practice Address - Fax:707-388-1896
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA145310106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist