Provider Demographics
NPI:1588044960
Name:TALLEY, RYAN (MA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:TALLEY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W 24TH ST APT E9
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-5725
Mailing Address - Country:US
Mailing Address - Phone:785-979-3193
Mailing Address - Fax:
Practice Address - Street 1:200 MAINE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1368
Practice Address - Country:US
Practice Address - Phone:785-843-9192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LMLP 2535103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical