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General NPI Number Information
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NPI Number | 1447522859
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Entity Type | Individual
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Provider Name | RYAN WOODROW WILKES PSYD
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Gender | Male
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Dates
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Enumeration Date | 01/31/2012
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Last Update Date | 01/09/2017
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Provider Practice Location Address
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Address Line | 1060 E 100 S SUITE 100
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City | SALT LAKE CITY
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State | UT
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Zip | 84102-1501
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Country | US
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Telephone | 801-590-0525
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Fax |
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Provider Business Mailing Address
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Address Line | 1443 E LAIRD AVE
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City | SALT LAKE CITY
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State | UT
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Zip | 84105-1938
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Country | US
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Telephone | 540-421-6660
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 10086571-2501
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY9246
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License Number State | FL
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