=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205659273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD NYDAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9185 E KENYON AVE STE 120
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80237-1856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-741-5588
-----------------------------------------------------
Fax | 303-741-9977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 480 S MARION PKWY APT 1603A
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80209-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-822-1536
-----------------------------------------------------
Fax | 303-741-9977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0000364
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------