Healthcare Provider Details

I. General information

NPI: 1205659273
Provider Name (Legal Business Name): RONALD NYDAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9185 E KENYON AVE STE 120
DENVER CO
80237-1856
US

IV. Provider business mailing address

480 S MARION PKWY APT 1603A
DENVER CO
80209-2559
US

V. Phone/Fax

Practice location:
  • Phone: 303-741-5588
  • Fax: 303-741-9977
Mailing address:
  • Phone: 616-822-1536
  • Fax: 303-741-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0000364
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: