Provider Demographics
NPI:1356891584
Name:WALLERIUS, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WALLERIUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 SCOTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-3523
Mailing Address - Country:US
Mailing Address - Phone:937-520-4942
Mailing Address - Fax:
Practice Address - Street 1:4800 SCOTHILLS DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-3523
Practice Address - Country:US
Practice Address - Phone:937-520-4942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.16006471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical