Healthcare Provider Details

I. General information

NPI: 1972835791
Provider Name (Legal Business Name): RYAN PAGE M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

43900 GARFIELD RD STE 222
CLINTON TOWNSHIP MI
48038-1137
US

IV. Provider business mailing address

11369 GREENDALE DR
STERLING HEIGHTS MI
48312-2926
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-1234
  • Fax:
Mailing address:
  • Phone: 586-949-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012507
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: