Provider Demographics
NPI:1407383169
Name:SHIMOKUBO, RYAN TAKEO (CADC-II)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:TAKEO
Last Name:SHIMOKUBO
Suffix:
Gender:M
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3865
Mailing Address - Country:US
Mailing Address - Phone:424-253-4638
Mailing Address - Fax:
Practice Address - Street 1:1741 PARK AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3865
Practice Address - Country:US
Practice Address - Phone:424-253-4638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA052270321101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)