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NPI Code Detail

MEDICARE: RYAN TYLON-ELIJAH FIELDS MHC, MPA

MEDICARE: RYAN TYLON-ELIJAH FIELDS MHC, MPA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health CounselorNY

General Provider Information

NPI Number : 1053938746
Entity Type Code : Individual
Provider Name (Legal Business Name) : RYAN TYLON-ELIJAH FIELDS MHC, MPA
Provider Business Mailing Address
First Line : 7323 210TH ST APT 3C
Second Line :
City : BAYSIDE
State : NY
Zip : 11364-2815
Country : US
Telephone Number : 718-506-5457
Fax Number :
Provider Business Practice Location Address
First Line : 5913 GROVE ST
Second Line :
City : RIDGEWOOD
State : NY
Zip : 11385-2647
Country : US
Telephone Number : 718-506-5457
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/29/2020
Last Update Date : 06/29/2020

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