Provider Demographics
NPI:1013597814
Name:ANDERSON, RYAN ROBERT
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BEVERLY LN
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-2439
Mailing Address - Country:US
Mailing Address - Phone:512-430-2616
Mailing Address - Fax:
Practice Address - Street 1:1464 E WHITESTONE BLVD STE 1301
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-9072
Practice Address - Country:US
Practice Address - Phone:512-710-8340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional