Provider Demographics
NPI:1356005367
Name:ETTNER, RYAN M (LMSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:ETTNER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14954 N COEUR DALENE ST
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-6484
Mailing Address - Country:US
Mailing Address - Phone:208-687-0538
Mailing Address - Fax:
Practice Address - Street 1:14954 N COEUR DALENE ST
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-6484
Practice Address - Country:US
Practice Address - Phone:208-687-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39709101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1437270097OtherALL PRIVATE INS UTILIZED