Provider Demographics
NPI:1629946058
Name:TUSTIN, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:TUSTIN
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 1:625 SE 16TH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2615
Mailing Address - Country:US
Mailing Address - Phone:360-619-2226
Mailing Address - Fax:360-326-9691
Practice Address - Street 1:1498 SE TECH CENTER PL STE 300
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5509
Practice Address - Country:US
Practice Address - Phone:360-619-2226
Practice Address - Fax:360-326-9691
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC70026234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health