Provider Demographics
NPI:1215501598
Name:TEIXEIRA, RYAN EMILY JO
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:EMILY JO
Last Name:TEIXEIRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:JO
Other - Last Name:RUGGIERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4740 MISSION GORGE PL
Mailing Address - Street 2:PO BOX 601541
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4227
Mailing Address - Country:US
Mailing Address - Phone:858-649-0117
Mailing Address - Fax:
Practice Address - Street 1:6244 EL CAJON BLVD STE 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3918
Practice Address - Country:US
Practice Address - Phone:619-640-3266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT144945106H00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician