MEDICARE: DR. RYAN J MATTEK PH.D.

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	103T00000X	Psychologist	3229-57	WI

General Provider Information

NPI Number	:	1780082701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN J MATTEK PH.D.

Provider Business Mailing Address
First Line	:	6650 W STATE ST
Second Line	:	SUITE 156
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-2827
Country	:	US
Telephone Number	:	414-491-0854
Fax Number	:

Provider Business Practice Location Address
First Line	:	6650 W STATE ST
Second Line	:	SUITE 156
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-2827
Country	:	US
Telephone Number	:	414-491-0854
Fax Number	:

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

Provider Enumeration Date	:	12/08/2014
Last Update Date	:	04/06/2017

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