Healthcare Provider Details

I. General information

NPI: 1639238173
Provider Name (Legal Business Name): MICHAEL RYAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 SE FEDERAL HWY
STUART FL
34994-4500
US

IV. Provider business mailing address

1008 SW HUNT CLUB CIR
PALM CITY FL
34990-2031
US

V. Phone/Fax

Practice location:
  • Phone: 772-485-8523
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH0001524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: