Provider Demographics
NPI:1447522859
Name:WILKES, RYAN WOODROW (PSYD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:WOODROW
Last Name:WILKES
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 E LAIRD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1938
Mailing Address - Country:US
Mailing Address - Phone:540-421-6660
Mailing Address - Fax:
Practice Address - Street 1:1060 E 100 S
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1501
Practice Address - Country:US
Practice Address - Phone:801-590-0525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10086571-2501103TC0700X
FLPY9246103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical