Provider Demographics
NPI:1104014273
Name:BLACKSTOCK, RYAN LEE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:LEE
Last Name:BLACKSTOCK
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9237 BECKER AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1563
Mailing Address - Country:US
Mailing Address - Phone:248-763-9194
Mailing Address - Fax:
Practice Address - Street 1:19366 ALLEN RD
Practice Address - Street 2:SUITE C
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-6809
Practice Address - Country:US
Practice Address - Phone:734-479-0949
Practice Address - Fax:734-479-1637
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-13
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013412103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist