Provider Demographics
NPI:1639625650
Name:RYAN, TYLER L (LPC-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:L
Last Name:RYAN
Suffix:
Gender:M
Credentials:LPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 W 109TH ST S
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-1817
Mailing Address - Country:US
Mailing Address - Phone:918-636-8896
Mailing Address - Fax:
Practice Address - Street 1:8810 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-3551
Practice Address - Country:US
Practice Address - Phone:918-212-8064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-19-76312106S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician