Healthcare Provider Details

I. General information

NPI: 1700397411
Provider Name (Legal Business Name): VIVIAN RYU LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E FRY BLVD, #3822
SIERRA VISTA AZ
85635
US

IV. Provider business mailing address

PO BOX 3822
SIERRA VISTA AZ
85636-3822
US

V. Phone/Fax

Practice location:
  • Phone: 520-559-4976
  • Fax:
Mailing address:
  • Phone: 520-559-4976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-16880
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: