Provider Demographics
NPI:1164917613
Name:MCGLYNN, RYAN MARK (LCSWA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MARK
Last Name:MCGLYNN
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-399-3755
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:1886 NC HWY S 133
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NC
Practice Address - Zip Code:28457
Practice Address - Country:US
Practice Address - Phone:910-259-0668
Practice Address - Fax:910-202-9966
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0150451041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC106S00000XMedicaid