Provider Demographics
NPI:1356621544
Name:COLE, RYAN L (PSYD, PSY)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:L
Last Name:COLE
Suffix:
Gender:M
Credentials:PSYD, PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 ELKTON DR STE 202
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 ELKTON DR STE 202
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3599
Practice Address - Country:US
Practice Address - Phone:224-715-2138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3942103TC0700X, 103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO328720Medicare PIN