Provider Demographics
NPI:1134709694
Name:RYAN, MICHAEL JOHN (BA, CADC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:RYAN
Suffix:
Gender:M
Credentials:BA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 AVENUE M W
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5789
Mailing Address - Country:US
Mailing Address - Phone:515-576-7261
Mailing Address - Fax:
Practice Address - Street 1:211 AVENUE M W
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5789
Practice Address - Country:US
Practice Address - Phone:515-576-7261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21033101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)