Provider Demographics
NPI:1336516020
Name:RYAN, CAROLYN (PHDLICMPHILMABCBAD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:PHDLICMPHILMABCBAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78-22 CLOVERDALE BLVD
Mailing Address - Street 2:UNIT B
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364
Mailing Address - Country:US
Mailing Address - Phone:917-335-2881
Mailing Address - Fax:
Practice Address - Street 1:7822 CLOVERDALE BLVD
Practice Address - Street 2:UNIT B
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-3124
Practice Address - Country:US
Practice Address - Phone:917-335-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000048-1103K00000X
NY018669-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst