Provider Demographics
NPI:1508447368
Name:STANLEY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:STANLEY
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 1:3606 N RANCHO DR STE 142
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3130
Mailing Address - Country:US
Mailing Address - Phone:702-778-5300
Mailing Address - Fax:702-778-5301
Practice Address - Street 1:3606 N RANCHO DR STE 142
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3130
Practice Address - Country:US
Practice Address - Phone:702-778-5300
Practice Address - Fax:702-778-5301
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCI3340101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100521663Medicaid