Basic Information
| Provider Information | |||||||||
| NPI: | 1407148588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENGDAHL | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PHD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRA CARE CIRCLE #2475 | ||||||||
| Address2: | CENTRA CARE HEALTH PLAZA | ||||||||
| City: | ST. CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202295199 | ||||||||
| FaxNumber: | 3202295109 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVENUE NORTH | ||||||||
| Address2: | ST. CLOUD HOSPITAL | ||||||||
| City: | ST. CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202295109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2011 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | LP5519 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.