Provider Demographics
NPI:1386416410
Name:DUSEK, RYAN JUSTIN (LADC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JUSTIN
Last Name:DUSEK
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10077 DOGWOOD ST NW STE 110
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-5285
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:
Practice Address - Street 1:10077 DOGWOOD ST NW STE 110
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-5285
Practice Address - Country:US
Practice Address - Phone:651-777-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)