Healthcare Provider Details

I. General information

NPI: 1972139947
Provider Name (Legal Business Name): KEVIN RYAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2020
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 E 2ND ST STE 210
THE DALLES OR
97058-1796
US

IV. Provider business mailing address

119 E 2ND ST STE 210
THE DALLES OR
97058-1796
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-6114
  • Fax: 541-296-6577
Mailing address:
  • Phone: 541-340-0402
  • Fax: 541-296-6577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN T RYAN
Title or Position: COUNSELOR / PRACTIONEER
Credential: LMFT
Phone: 541-296-6114