Provider Demographics
NPI:1528042850
Name:RYAN, TIMOTHY JAMES (LICSW, BCD)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:RYAN
Suffix:
Gender:M
Credentials:LICSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 INDUSTRIAL PARK RD
Mailing Address - Street 2:INTEGRATED COUNSELING CENTERS, INC.
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4829
Mailing Address - Country:US
Mailing Address - Phone:508-830-9562
Mailing Address - Fax:508-830-6735
Practice Address - Street 1:64 INDUSTRIAL PARK RD
Practice Address - Street 2:INTEGRATED COUNSELING CENTERS, INC.
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4829
Practice Address - Country:US
Practice Address - Phone:508-830-9562
Practice Address - Fax:508-830-6735
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105196104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04609OtherBLUECROSS BLUESHIELD
MAP04609OtherBLUECROSS BLUESHIELD