Healthcare Provider Details

I. General information

NPI: 1245028331
Provider Name (Legal Business Name): RYAN VAN VUITTON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6409 E MILL PLAIN BLVD
VANCOUVER WA
98661-7454
US

IV. Provider business mailing address

8604 NE 26TH CIR
VANCOUVER WA
98662-7549
US

V. Phone/Fax

Practice location:
  • Phone: 360-718-8376
  • Fax:
Mailing address:
  • Phone: 360-809-1885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB61645364
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: