Provider Demographics
NPI:1578893129
Name:RYAN, RANDY LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LYNN
Last Name:RYAN
Suffix:
Gender:F
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 17586
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-0586
Mailing Address - Country:US
Mailing Address - Phone:801-913-0098
Mailing Address - Fax:801-272-3857
Practice Address - Street 1:8823 S REDWOOD RD
Practice Address - Street 2:SUITE B BASEMENT
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9281
Practice Address - Country:US
Practice Address - Phone:801-913-0098
Practice Address - Fax:801-272-3857
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6390681-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000068519OtherMEDICARE PTAN