Provider Demographics
NPI:1376434597
Name:THEISEN, RYAN O (LADC, LPCC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:O
Last Name:THEISEN
Suffix:
Gender:M
Credentials:LADC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 XENIUM LN N STE 130
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2623
Mailing Address - Country:US
Mailing Address - Phone:612-564-3535
Mailing Address - Fax:763-545-8150
Practice Address - Street 1:2950 XENIUM LN N STE 130
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2623
Practice Address - Country:US
Practice Address - Phone:612-564-3535
Practice Address - Fax:763-545-8150
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306571101YA0400X
MN5099101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)