MEDICARE: RYAN LEYBAS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6615111-3501	UT

General Provider Information

NPI Number	:	1679741623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN LEYBAS LCSW

Provider Business Mailing Address
First Line	:	1174 E GRAYSTONE WAY STE 6
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2671
Country	:	US
Telephone Number	:	801-277-2129
Fax Number	:	801-649-5651

Provider Business Practice Location Address
First Line	:	1174 E GRAYSTONE WAY STE 6
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2671
Country	:	US
Telephone Number	:	801-277-2129
Fax Number	:	801-649-5651

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2008
Last Update Date	:	07/14/2011

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