Healthcare Provider Details

I. General information

NPI: 1104733708
Provider Name (Legal Business Name): RYAN MCGOUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 HURLBUTT ST
WILTON CT
06897-3212
US

IV. Provider business mailing address

51 HURLBUTT ST
WILTON CT
06897-3212
US

V. Phone/Fax

Practice location:
  • Phone: 203-747-0104
  • Fax:
Mailing address:
  • Phone: 203-747-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9383
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: