Provider Demographics
NPI:1497315063
Name:RYAN, MARY BETH (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PEACHTREE CT STE 105
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:140 WASHINGTON AVENUE EXT APT D58
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5386
Practice Address - Country:US
Practice Address - Phone:518-869-6800
Practice Address - Fax:518-869-6800
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010809235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist