1528042850 NPI number — MR. TIMOTHY JAMES RYAN LICSW, BCD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528042850 NPI number — MR. TIMOTHY JAMES RYAN LICSW, BCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN
Provider First Name:
TIMOTHY
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICSW, BCD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528042850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 INDUSTRIAL PARK RD
Provider Second Line Business Mailing Address:
INTEGRATED COUNSELING CENTERS, INC.
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-4829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-830-9562
Provider Business Mailing Address Fax Number:
508-830-6735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 INDUSTRIAL PARK RD
Provider Second Line Business Practice Location Address:
INTEGRATED COUNSELING CENTERS, INC.
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360-4829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-830-9562
Provider Business Practice Location Address Fax Number:
508-830-6735
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  105196 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P04609 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com