Provider Demographics
NPI:1285758698
Name:VANWINKLE, RYAN CLARKE (LPC)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:CLARKE
Last Name:VANWINKLE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:402 ELSIE STREET
Mailing Address - City:VAN BUREN
Mailing Address - State:MO
Mailing Address - Zip Code:63965-0894
Mailing Address - Country:US
Mailing Address - Phone:573-323-4139
Mailing Address - Fax:
Practice Address - Street 1:402 ELSIE ST.
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:MO
Practice Address - Zip Code:63965
Practice Address - Country:US
Practice Address - Phone:573-323-0411
Practice Address - Fax:573-323-0412
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017414101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495869224Medicaid