MEDICARE: TYLER J RYAN

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
1	103TC0700X	Clinical Psychologist	265975	KY

General Provider Information

NPI Number	:	1467050856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER J RYAN

Provider Business Mailing Address
First Line	:	1879 SAINT JAMES PL
Second Line	:
City	:	VERONA
State	:	KY
Zip	:	41092-8325
Country	:	US
Telephone Number	:	859-489-4299
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 HOUSTON RD
Second Line	:
City	:	ERLANGER
State	:	KY
Zip	:	41018-3402
Country	:	US
Telephone Number	:	859-727-6700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2020
Last Update Date	:	10/16/2020

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