MEDICARE: NOLAN RYAN FELLOWS CST, LCPC, LPC

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	101YM0800X	Mental Health Counselor	LCPC-9689	ID
2	101YM0800X	Mental Health Counselor	LPC.0023097	CO

General Provider Information

NPI Number	:	1790302768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOLAN RYAN FELLOWS CST, LCPC, LPC

Provider Business Mailing Address
First Line	:	618 E MYRTLE ST UNIT A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3282
Country	:	US
Telephone Number	:	208-841-6747
Fax Number	:

Provider Business Practice Location Address
First Line	:	618 E MYRTLE ST UNIT A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3282
Country	:	US
Telephone Number	:	208-841-6747
Fax Number	:

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

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	01/27/2026

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