MEDICARE: MR. MARK C RYAN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	073546	NY

General Provider Information

NPI Number	:	1912038514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK C RYAN LCSW

Provider Business Mailing Address
First Line	:	365 CLINTON AVE
Second Line	:	APT 10 H
City	:	BROOKLYN
State	:	NY
Zip	:	11238-1176
Country	:	US
Telephone Number	:	917-282-3782
Fax Number	:

Provider Business Practice Location Address
First Line	:	360 9TH AVE
Second Line	:	FLOOR 2
City	:	BROOKLYN
State	:	NY
Zip	:	11215
Country	:	US
Telephone Number	:	718-230-7151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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