Healthcare Provider Details

I. General information

NPI: 1891167474
Provider Name (Legal Business Name): RYAN BUSALACCHI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 ZANG ST
LAKEWOOD CO
80228-1052
US

IV. Provider business mailing address

421 ZANG ST
LAKEWOOD CO
80228-1052
US

V. Phone/Fax

Practice location:
  • Phone: 303-996-3844
  • Fax:
Mailing address:
  • Phone: 928-853-2836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number0204323
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: