Provider Demographics
NPI:1588607279
Name:MACKS, RYAN J (PHD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:MACKS
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 1:7799 JOAN DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-3682
Mailing Address - Country:US
Mailing Address - Phone:513-204-5746
Mailing Address - Fax:513-229-3707
Practice Address - Street 1:7799 JOAN DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-3682
Practice Address - Country:US
Practice Address - Phone:513-204-5746
Practice Address - Fax:513-229-3707
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6162103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH177201Medicare PIN