Healthcare Provider Details

I. General information

NPI: 1992415202
Provider Name (Legal Business Name): RYAN ROBERT VANNATTER BSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43825 MICHIGAN AVE
CANTON MI
48188-2551
US

IV. Provider business mailing address

4780 WASHTENAW AVE
ANN ARBOR MI
48108-3409
US

V. Phone/Fax

Practice location:
  • Phone: 734-397-3088
  • Fax:
Mailing address:
  • Phone: 248-880-7292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: