Provider Demographics
NPI:1407148588
Name:ENGDAHL, RYAN MICHAEL (PHD, LP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:ENGDAHL
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRA CARE CIRCLE #2475
Mailing Address - Street 2:CENTRA CARE HEALTH PLAZA
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-229-5199
Mailing Address - Fax:320-229-5109
Practice Address - Street 1:1406 6TH AVENUE NORTH
Practice Address - Street 2:ST. CLOUD HOSPITAL
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-229-5109
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MNLP5519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist