Provider Demographics
NPI:1720241847
Name:COPPAGE, RYAN MARTIN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MARTIN
Last Name:COPPAGE
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 1:4343 WILLIAMSBOURGH DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823
Mailing Address - Country:US
Mailing Address - Phone:916-395-3552
Mailing Address - Fax:
Practice Address - Street 1:7171 BOWLING DR STE 300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2043
Practice Address - Country:US
Practice Address - Phone:916-394-9195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)