Healthcare Provider Details

I. General information

NPI: 1386891786
Provider Name (Legal Business Name): RYAN L CLEMENTS PSY.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 N COUNTRY RD UNIT L
STONY BROOK NY
11790-1924
US

IV. Provider business mailing address

1099 N COUNTRY RD UNIT L
STONY BROOK NY
11790-1924
US

V. Phone/Fax

Practice location:
  • Phone: 631-941-2210
  • Fax:
Mailing address:
  • Phone: 631-941-2210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number016820
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number016820
License Number StateNY

VIII. Authorized Official

Name: DR. RYAN CLEMENTS
Title or Position: PSYCHOLOGIST / OWNER
Credential: PSY.D.
Phone: 631-626-4459