=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720017171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN RYAN PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 07/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 SECOND AVENUE, BLDG. C, SUITE 650
-----------------------------------------------------
City | COLLEGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-306-4774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 SECOND AVENUE, BLDG. C, SUITE 650
-----------------------------------------------------
City | COLLEGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-306-4774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 3024
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSO15316
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------