Provider Demographics
NPI:1104064153
Name:EMERSON, RYAN JOEL (LMHC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JOEL
Last Name:EMERSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-2042
Mailing Address - Country:US
Mailing Address - Phone:641-510-1381
Mailing Address - Fax:641-243-2149
Practice Address - Street 1:807 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-2042
Practice Address - Country:US
Practice Address - Phone:641-510-1381
Practice Address - Fax:641-243-2149
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074580101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4226765Medicaid