Provider Demographics
NPI:1083335418
Name:RYAN, DOUGLAS DEVIN (CMT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:DEVIN
Last Name:RYAN
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 VIA ADRIAN
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7026
Mailing Address - Country:US
Mailing Address - Phone:310-293-3806
Mailing Address - Fax:
Practice Address - Street 1:44 VIA ADRIAN
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-7026
Practice Address - Country:US
Practice Address - Phone:310-293-3806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist