Healthcare Provider Details

I. General information

NPI: 1891609632
Provider Name (Legal Business Name): RYAN TIMOTHY FLANAGAN LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 BONFORTE BLVD
PUEBLO CO
81001-1602
US

IV. Provider business mailing address

1615 BONFORTE BLVD
PUEBLO CO
81001-1602
US

V. Phone/Fax

Practice location:
  • Phone: 719-404-1992
  • Fax:
Mailing address:
  • Phone: 719-404-1992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW.0009927900
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: