=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386891786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RYAN L CLEMENTS PSY.D. LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2008
-----------------------------------------------------
Last Update Date | 08/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1099 N COUNTRY RD UNIT L
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-941-2210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1099 N COUNTRY RD UNIT L
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11790-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-941-2210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST / OWNER
-----------------------------------------------------
Name | DR. RYAN CLEMENTS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 631-626-4459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 016820
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 016820
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------