Provider Demographics
NPI:1336167261
Name:TORNGREN, RYAN C (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:C
Last Name:TORNGREN
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 OVERLAND AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2929
Mailing Address - Country:US
Mailing Address - Phone:208-677-5332
Mailing Address - Fax:208-677-4002
Practice Address - Street 1:2241 OVERLAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2929
Practice Address - Country:US
Practice Address - Phone:208-677-5332
Practice Address - Fax:208-677-4002
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-27457104100000X
IDLCSW-296331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker