Provider Demographics
NPI:1679827430
Name:NIELSEN, RYAN S (APC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:S
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4711
Mailing Address - Country:US
Mailing Address - Phone:801-225-1155
Mailing Address - Fax:801-255-0281
Practice Address - Street 1:1258 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4711
Practice Address - Country:US
Practice Address - Phone:801-225-1155
Practice Address - Fax:801-255-0281
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT311404-6009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional