Healthcare Provider Details

I. General information

NPI: 1497112833
Provider Name (Legal Business Name): RYAN CROSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9930 EVERGREEN WAY SUITE Z-154
EVERETT WA
98204-3883
US

IV. Provider business mailing address

9930 EVERGREEN WAY SUITE Z-154
EVERETT WA
98204-3883
US

V. Phone/Fax

Practice location:
  • Phone: 425-347-5121
  • Fax: 425-353-6425
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60453972
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: