Provider Demographics
NPI:1538179577
Name:WETZLER, RYAN GLENN (PSYD, DBSM, ABPP)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:GLENN
Last Name:WETZLER
Suffix:
Gender:M
Credentials:PSYD, DBSM, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FAIRFAX AVE STE 100C
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4948
Mailing Address - Country:US
Mailing Address - Phone:502-822-1320
Mailing Address - Fax:844-825-9171
Practice Address - Street 1:130 FAIRFAX AVE STE 100C
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4948
Practice Address - Country:US
Practice Address - Phone:502-822-1320
Practice Address - Fax:844-825-9171
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042307A103T00000X, 103TB0200X, 103TC0700X, 103TH0004X, 173F00000X
KY129449103T00000X, 103TB0200X, 103TC0700X, 173F00000X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No173F00000XOther Service ProvidersSleep Specialist, PhD
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000370091OtherANTHEM
KY2646422000OtherPASSPORT ADVANTAGE
KYQ30844Medicare UPIN
KY000000370091OtherANTHEM
IN258300CMedicare PIN