Healthcare Provider Details

I. General information

NPI: 1811962632
Provider Name (Legal Business Name): MARY AGNES RYAN PHD LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21751 ECORSE RD
TAYLOR MI
48180-1846
US

IV. Provider business mailing address

21751 ECORSE RD
TAYLOR MI
48180-1846
US

V. Phone/Fax

Practice location:
  • Phone: 313-291-7000
  • Fax: 313-291-0942
Mailing address:
  • Phone: 313-291-7000
  • Fax: 313-291-0942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301003136
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: