=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609454768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN DOUGLAS HEATH MA, PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2021
-----------------------------------------------------
Last Update Date | 03/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2705 CHERRY HILLS DR
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61822-7538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-704-1768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7626 BROWN GULF RD
-----------------------------------------------------
City | JAMESVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13078-9636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-578-0014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.019549
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------