MEDICARE: MR. RYAN CONNOR M.A., LPC

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	101YP2500X	Professional Counselor	1852	WV
2	101YP2500X	Professional Counselor	C3999	OR

General Provider Information

NPI Number	:	1851575211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN CONNOR M.A., LPC

Provider Business Mailing Address
First Line	:	PO BOX 729
Second Line	:
City	:	AMITY
State	:	OR
Zip	:	97101
Country	:	US
Telephone Number	:	503-857-7501
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 GOUCHER ST.
Second Line	:
City	:	AMITY
State	:	OR
Zip	:	97101
Country	:	US
Telephone Number	:	503-857-7501
Fax Number	:

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

Provider Enumeration Date	:	12/20/2007
Last Update Date	:	09/02/2016

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