Provider Demographics
NPI:1164506341
Name:RYAN, JOHN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:RYAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1405
Mailing Address - Country:US
Mailing Address - Phone:313-884-5544
Mailing Address - Fax:
Practice Address - Street 1:22811 GREATER MACK AVE
Practice Address - Street 2:SUITE L-3
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-777-3988
Practice Address - Fax:586-777-9879
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G44582Medicare ID - Type Unspecified