Provider Demographics
NPI:1366969016
Name:BLACK, RYAN (LICSW)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 40TH AVE SW # N315
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4674
Mailing Address - Country:US
Mailing Address - Phone:616-886-0960
Mailing Address - Fax:
Practice Address - Street 1:4710 40TH AVE SW # N315
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4674
Practice Address - Country:US
Practice Address - Phone:616-886-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA612467741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical