Provider Demographics
NPI:1588057400
Name:LAINE, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LAINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 N LUKE ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6651
Mailing Address - Country:US
Mailing Address - Phone:530-680-3010
Mailing Address - Fax:
Practice Address - Street 1:11350 E PALMER WASILLA HWY
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7425
Practice Address - Country:US
Practice Address - Phone:530-680-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK208457101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health