Provider Demographics
NPI:1467050856
Name:RYAN, TYLER J
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1879 SAINT JAMES PL
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:KY
Mailing Address - Zip Code:41092-8325
Mailing Address - Country:US
Mailing Address - Phone:859-489-4299
Mailing Address - Fax:
Practice Address - Street 1:4220 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-3402
Practice Address - Country:US
Practice Address - Phone:859-727-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical