Provider Demographics
NPI:1508966177
Name:RYAN, DIANE CAROL (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CAROL
Last Name:RYAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 LONDON ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2723
Mailing Address - Country:US
Mailing Address - Phone:917-402-7237
Mailing Address - Fax:732-414-2489
Practice Address - Street 1:55-77 SCHANCK RD
Practice Address - Street 2:STE B-11
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2964
Practice Address - Country:US
Practice Address - Phone:917-402-7237
Practice Address - Fax:732-414-2489
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010846225100000X
NJ40QA01639500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ67532Medicare ID - Type UnspecifiedPHYSICAL THERAPY PROVIDER