Provider Demographics
NPI:1023340395
Name:HENRY, RYAN M (LICSW)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:M
Last Name:HENRY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318
Mailing Address - Country:US
Mailing Address - Phone:701-263-1088
Mailing Address - Fax:701-263-3791
Practice Address - Street 1:73 ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318
Practice Address - Country:US
Practice Address - Phone:701-263-1088
Practice Address - Fax:701-263-3791
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3310104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker