Healthcare Provider Details

I. General information

NPI: 1730878471
Provider Name (Legal Business Name): RYAN OLIVER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 MAIN ST
FARMINGTON CT
06032-2912
US

IV. Provider business mailing address

485 MAIN ST
FARMINGTON CT
06032-2912
US

V. Phone/Fax

Practice location:
  • Phone: 860-893-5708
  • Fax:
Mailing address:
  • Phone: 860-893-5708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12995
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number12995
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: