Healthcare Provider Details

I. General information

NPI: 1003370768
Provider Name (Legal Business Name): RYAN BOLANDER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 S 1070 W STE B
SALT LAKE CITY UT
84119-1570
US

IV. Provider business mailing address

117 W 400 S
SALT LAKE CITY UT
84101-1916
US

V. Phone/Fax

Practice location:
  • Phone: 385-500-2986
  • Fax:
Mailing address:
  • Phone: 385-200-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11048314-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: