Healthcare Provider Details

I. General information

NPI: 1104064153
Provider Name (Legal Business Name): RYAN JOEL EMERSON LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 4TH AVE
GRINNELL IA
50112-2042
US

IV. Provider business mailing address

807 4TH AVE
GRINNELL IA
50112-2042
US

V. Phone/Fax

Practice location:
  • Phone: 641-510-1381
  • Fax: 641-243-2149
Mailing address:
  • Phone: 641-510-1381
  • Fax: 641-243-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number074580
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: