Healthcare Provider Details

I. General information

NPI: 1932418183
Provider Name (Legal Business Name): MARY WHITNEY RYAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 03/02/2024
Certification Date: 03/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 E LAKESIDE AVE STE B001
COEUR D ALENE ID
83814-2834
US

IV. Provider business mailing address

711 N 8TH ST
COEUR D ALENE ID
83814-4255
US

V. Phone/Fax

Practice location:
  • Phone: 208-243-8080
  • Fax:
Mailing address:
  • Phone: 305-710-2877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60440889
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY8457
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60440889
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY60440889
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: