Basic Information
| Provider Information | |||||||||
| NPI: | 1174908651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | L.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 948 ROSE ST | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805014113 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1905 W 8TH ST | ||||||||
| Address2: | #209 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805375224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707757061 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2015 | ||||||||
| LastUpdateDate: | 07/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LSW.0009920748 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.