=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801558192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN NOEL PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2021
-----------------------------------------------------
Last Update Date | 10/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 257 DEERING AVE STE 201
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04103-4858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-910-2021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 DOUGHTY FARM RD
-----------------------------------------------------
City | GRAY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04039-9301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-926-9168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS2463
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------