Healthcare Provider Details

I. General information

NPI: 1255805131
Provider Name (Legal Business Name): RYAN ZIMMERMAN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15655 W ROOSEVELT ST
GOODYEAR AZ
85338-9282
US

IV. Provider business mailing address

PO BOX 7405
GOODYEAR AZ
85338-0641
US

V. Phone/Fax

Practice location:
  • Phone: 623-451-5917
  • Fax:
Mailing address:
  • Phone: 623-337-2275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-17247
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: