Healthcare Provider Details

I. General information

NPI: 1063990984
Provider Name (Legal Business Name): RYAN EVANS COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12728 AUGUSTA AVE STE 150
OMAHA NE
68144-3753
US

IV. Provider business mailing address

12728 AUGUSTA AVE STE 150
OMAHA NE
68144-3753
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-1537
  • Fax: 402-330-9331
Mailing address:
  • Phone: 402-330-1537
  • Fax: 402-330-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1189
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1692
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNE

VIII. Authorized Official

Name: MR. RYAN THOMAS EVANS
Title or Position: OWNER
Credential: LIMHP, LADC
Phone: 402-330-1537