Provider Demographics
NPI:1205659273
Name:NYDAM, RONALD
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:NYDAM
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 1:480 S MARION PKWY APT 1603A
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2559
Mailing Address - Country:US
Mailing Address - Phone:616-822-1536
Mailing Address - Fax:303-741-9977
Practice Address - Street 1:9185 E KENYON AVE STE 120
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-1856
Practice Address - Country:US
Practice Address - Phone:303-741-5588
Practice Address - Fax:303-741-9977
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000364101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional