Provider Demographics
NPI:1336152644
Name:RYALS, PAUL CARLETON (LICSW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CARLETON
Last Name:RYALS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6529 44TH AVENUE NORTH
Mailing Address - Street 2:6529 44TH AVE NORTH
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428
Mailing Address - Country:US
Mailing Address - Phone:763-537-1886
Mailing Address - Fax:
Practice Address - Street 1:7362 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3142
Practice Address - Country:US
Practice Address - Phone:763-503-3981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN167891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6255168OtherMEDICA
MN246058100Medicaid
MN8G624DIOtherBLUE CROSS/BLUE SHIELD
MN8G624DIOtherBLUE CROSS/BLUE SHIELD