Provider Demographics
NPI:1609248962
Name:VARGAS, RYAN D (LLMSW, CADC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:VARGAS
Suffix:
Gender:M
Credentials:LLMSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-1236
Mailing Address - Country:US
Mailing Address - Phone:517-205-2732
Mailing Address - Fax:517-205-0112
Practice Address - Street 1:2424 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-1236
Practice Address - Country:US
Practice Address - Phone:517-205-2732
Practice Address - Fax:517-205-0112
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01111101YA0400X
MI68010976121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)