Provider Demographics
NPI:1073567889
Name:RYAN, DORIS ODELL (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:ODELL
Last Name:RYAN
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 E US HIGHWAY 36
Mailing Address - Street 2:STE 100
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6646
Mailing Address - Country:US
Mailing Address - Phone:317-347-0625
Mailing Address - Fax:
Practice Address - Street 1:6655 US 36 EAST
Practice Address - Street 2:CUMMINS BEHAVIORAL HEALTH SERVICES
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123
Practice Address - Country:US
Practice Address - Phone:317-272-3330
Practice Address - Fax:317-272-0807
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041969A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000342263OtherANTHEM BCBS PROVIDER PIN
IN200305580Medicaid
INS04457Medicare UPIN
344840MMedicare PIN