Provider Demographics
NPI:1265844815
Name:BURKE, RYAN (LPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BURKE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11390
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1390
Mailing Address - Country:US
Mailing Address - Phone:307-733-3908
Mailing Address - Fax:307-734-0017
Practice Address - Street 1:610 W BROADWAY AVE
Practice Address - Street 2:STE L1
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8213
Practice Address - Country:US
Practice Address - Phone:307-733-3908
Practice Address - Fax:307-734-0017
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC 830101YA0400X
WYLPC-1544101YP2500X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional