Provider Demographics
NPI:1346625860
Name:ABRAHAM, RYAN (PSYD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ABRAHAM
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 586
Mailing Address - Street 2:
Mailing Address - City:OTTERBEIN
Mailing Address - State:IN
Mailing Address - Zip Code:47970-0586
Mailing Address - Country:US
Mailing Address - Phone:765-583-0186
Mailing Address - Fax:765-583-0189
Practice Address - Street 1:606 LIMERICK LN.
Practice Address - Street 2:
Practice Address - City:OTTERBEIN
Practice Address - State:IN
Practice Address - Zip Code:47970-0586
Practice Address - Country:US
Practice Address - Phone:765-583-0186
Practice Address - Fax:765-583-0189
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IN20043141A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor