Provider Demographics
NPI:1497296461
Name:KNUTSON, RYAN D (CSAC, LPC, ICS-IT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:CSAC, LPC, ICS-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 TRAVIS ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6343
Mailing Address - Country:US
Mailing Address - Phone:608-386-6080
Mailing Address - Fax:
Practice Address - Street 1:571 BRAUND ST
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650
Practice Address - Country:US
Practice Address - Phone:608-785-7000
Practice Address - Fax:608-785-7477
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16064101YA0400X
WI2777101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100065209Medicaid