Provider Demographics
NPI:1891542510
Name:BRASE, RYAN EDWARD (LAC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWARD
Last Name:BRASE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6784 W WETHERSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-9602
Mailing Address - Country:US
Mailing Address - Phone:602-483-9897
Mailing Address - Fax:
Practice Address - Street 1:6784 W WETHERSFIELD RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-9602
Practice Address - Country:US
Practice Address - Phone:602-483-9897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18718101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor