Provider Demographics
NPI:1205199841
Name:RYAN, KATHERINE K (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:K
Last Name:RYAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2442
Mailing Address - Country:US
Mailing Address - Phone:508-284-1210
Mailing Address - Fax:
Practice Address - Street 1:41 DONALD B DEAN DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3252
Practice Address - Country:US
Practice Address - Phone:207-661-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1334103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003258701Medicare PIN