Provider Demographics
NPI:1588194799
Name:COUILLOU, RYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:COUILLOU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 PINE CONE CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1967
Mailing Address - Country:US
Mailing Address - Phone:770-833-9528
Mailing Address - Fax:
Practice Address - Street 1:2704 N OAK ST BLDG A1
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5901
Practice Address - Country:US
Practice Address - Phone:770-833-9528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003815103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist