Provider Demographics
NPI:1225346935
Name:DIX, RYAN C (PSYD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:DIX
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT
Practice Address - Street 2:SUITE 540
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2985
Practice Address - Country:US
Practice Address - Phone:503-215-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2102103TC0700X
OR16500000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500626193Medicaid
OR12152292OtherCAQH ID
ORR155739Medicare PIN