Provider Demographics
NPI:1952052839
Name:POULSEN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:POULSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S 700 E STE 2A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2940 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-6614
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician