Healthcare Provider Details

I. General information

NPI: 1417788639
Provider Name (Legal Business Name): RYAN SCOTT THOMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4516 S 700 E
SALT LAKE CITY UT
84107-4192
US

IV. Provider business mailing address

1425 S 700 E STE 102
SALT LAKE CITY UT
84105-2125
US

V. Phone/Fax

Practice location:
  • Phone: 385-313-0055
  • Fax:
Mailing address:
  • Phone: 385-300-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13386083-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: