Healthcare Provider Details

I. General information

NPI: 1104281237
Provider Name (Legal Business Name): RYAN IBARRA LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 W SEAWAY DR
NORTON SHORES MI
49444-3756
US

IV. Provider business mailing address

1306 DICKINSON, SE
GRAND RAPIDS MICHIGAN
49507
UM

V. Phone/Fax

Practice location:
  • Phone: 231-375-8063
  • Fax:
Mailing address:
  • Phone: 616-490-1189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011239
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: