Basic Information
| Provider Information | |||||||||
| NPI: | 1720534514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEATS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 569 FAIRVIEW AVE S | ||||||||
| Address2: | |||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127092104 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | #110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.