Provider Demographics
NPI:1467269175
Name:WILKINSON, RYAN JAMES (LMSW)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 N 400 E APT F
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-8549
Mailing Address - Country:US
Mailing Address - Phone:801-228-7082
Mailing Address - Fax:
Practice Address - Street 1:1275 N 400 E APT F
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-8549
Practice Address - Country:US
Practice Address - Phone:801-228-7082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCADC-5082101YA0400X
IDLMSW-45129101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)