Provider Demographics
NPI:1255805131
Name:ZIMMERMAN, RYAN (LAC)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7405
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0641
Mailing Address - Country:US
Mailing Address - Phone:623-337-2275
Mailing Address - Fax:
Practice Address - Street 1:15655 W ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9282
Practice Address - Country:US
Practice Address - Phone:623-451-5917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17247101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health