Provider Demographics
NPI:1720470628
Name:RYNEARSON, KYM
Entity Type:Individual
Prefix:
First Name:KYM
Middle Name:
Last Name:RYNEARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 MILLER WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1332
Mailing Address - Country:US
Mailing Address - Phone:916-451-9312
Mailing Address - Fax:916-451-4018
Practice Address - Street 1:4049 MILLER WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1332
Practice Address - Country:US
Practice Address - Phone:916-451-9312
Practice Address - Fax:916-451-4018
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94-1582683324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR117281214OtherAOD COUNSELOR