Provider Demographics
NPI:1306033022
Name:RYSER, REBECCA (PHD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:RYSER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:RYSER
Other - Last Name:JOLLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1089 FALLBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-0757
Mailing Address - Country:US
Mailing Address - Phone:801-568-1431
Mailing Address - Fax:
Practice Address - Street 1:8522 S 1300 E
Practice Address - Street 2:SUITE D106
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-1391
Practice Address - Country:US
Practice Address - Phone:801-565-0821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT115990-3501104100000X
UT115990-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UMedicare UPIN
UTU000074487Medicare UPIN