Provider Demographics
NPI:1275808818
Name:VIVIANO, RYAN BLAIR (LCSW, LCDC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:BLAIR
Last Name:VIVIANO
Suffix:
Gender:M
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:BLAIR
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:ATTN: BILLING CREDENTIALING
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:713-559-3256
Practice Address - Street 1:1415 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-2602
Practice Address - Country:US
Practice Address - Phone:832-548-5000
Practice Address - Fax:713-351-7361
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX560561041C0700X
TX12678101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080462703OtherLEGACY COMMUNITY HEALTH SERVICES INC. MEDICAID #
741843OtherLEGACY COMMUNITY HEALTH SERVICES INC SITE MEDICARE