Provider Demographics
NPI:1265765259
Name:DOUGLAS, RYAN (LCSW)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 SHOREHAM PL STE 330
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5976
Mailing Address - Country:US
Mailing Address - Phone:707-799-8875
Mailing Address - Fax:
Practice Address - Street 1:1244 SOLSTICE LN
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1253
Practice Address - Country:US
Practice Address - Phone:707-799-8875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099238231041C0700X
CA87343101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical