Provider Demographics
NPI:1518436914
Name:PARKE, RYAN (CASUDC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PARKE
Suffix:
Gender:M
Credentials:CASUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 W 200 N STE 200
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4505
Mailing Address - Country:US
Mailing Address - Phone:435-634-5600
Mailing Address - Fax:
Practice Address - Street 1:474 W 200 N STE 200
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4505
Practice Address - Country:US
Practice Address - Phone:435-634-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10564656-6018101YA0400X
UT10564656-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)