Provider Demographics
NPI:1497112833
Name:CROSS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9930 EVERGREEN WAY
Mailing Address - Street 2:SUITE Z-154
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-3883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9930 EVERGREEN WAY
Practice Address - Street 2:SUITE Z-154
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3883
Practice Address - Country:US
Practice Address - Phone:425-347-5121
Practice Address - Fax:425-353-6425
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60453972101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)