Healthcare Provider Details

I. General information

NPI: 1811405632
Provider Name (Legal Business Name): RYAN MOYLAN MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 WOOD RD STE 206
BRAINTREE MA
02184-2508
US

IV. Provider business mailing address

32 SASSAMON AVE
MILTON MA
02186-5816
US

V. Phone/Fax

Practice location:
  • Phone: 978-222-3121
  • Fax:
Mailing address:
  • Phone: 781-964-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12757
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: