Provider Demographics
NPI:1073963740
Name:AUSTIN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3179 W DEVILS DEN RD
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460
Mailing Address - Country:US
Mailing Address - Phone:580-222-9002
Mailing Address - Fax:
Practice Address - Street 1:717B HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-8253
Practice Address - Country:US
Practice Address - Phone:580-564-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor