Provider Demographics
NPI:1053689356
Name:HULBERT, RYAN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
Last Name:HULBERT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24108 TEN DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660-7212
Mailing Address - Country:US
Mailing Address - Phone:208-722-5033
Mailing Address - Fax:
Practice Address - Street 1:2273 E GALA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-898-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-282103T00000X, 103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling