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General NPI Number Information
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NPI Number | 1417746413
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Entity Type | Individual
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Provider Name | MARK ANTHONY RYAN LPA
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Gender | Male
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Dates
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Enumeration Date | 05/05/2025
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Last Update Date | 05/05/2025
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Provider Practice Location Address
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Address Line | 3504 PRIMROSE AVE
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City | FORT WORTH
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State | TX
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Zip | 76111-4945
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Country | US
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Telephone | 817-726-7504
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Fax |
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Provider Business Mailing Address
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Address Line | 3504 PRIMROSE AVE
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City | FORT WORTH
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State | TX
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Zip | 76111-4945
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Country | US
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Telephone | 817-726-7504
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TM1800X
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Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
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License Number | 34184
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number | 34184
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License Number State | TX
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