Provider Demographics
NPI:1720434566
Name:LOISELLE, RYAN SCOTT (LPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:LOISELLE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7949 SE GLENCOE RD # 13
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-1035
Mailing Address - Country:US
Mailing Address - Phone:415-305-9998
Mailing Address - Fax:
Practice Address - Street 1:3620 SE POWELL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1880
Practice Address - Country:US
Practice Address - Phone:503-673-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR4492101YM0800X
ORC5073101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR462796848Medicaid