Provider Demographics
NPI:1073754982
Name:RYAN, MOIRA
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 BRUSH ST APT 2911
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4340
Mailing Address - Country:US
Mailing Address - Phone:503-468-6998
Mailing Address - Fax:
Practice Address - Street 1:555 BRUSH ST APT 2911
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-4340
Practice Address - Country:US
Practice Address - Phone:503-468-6998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 372600000X
PAPC011590101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No372600000XNursing Service Related ProvidersAdult Companion