Provider Demographics
NPI:1790295780
Name:SHOOK, RYLAN
Entity Type:Individual
Prefix:
First Name:RYLAN
Middle Name:
Last Name:SHOOK
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 1:10635 NE FARGO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2758
Mailing Address - Country:US
Mailing Address - Phone:716-795-2687
Mailing Address - Fax:
Practice Address - Street 1:10635 NE FARGO ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2758
Practice Address - Country:US
Practice Address - Phone:207-251-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61020407106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist