Provider Demographics
NPI:1609454768
Name:HEATH, RYAN DOUGLAS (MA, PHD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DOUGLAS
Last Name:HEATH
Suffix:
Gender:M
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7626 BROWN GULF RD
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-9636
Mailing Address - Country:US
Mailing Address - Phone:978-578-0014
Mailing Address - Fax:
Practice Address - Street 1:2705 CHERRY HILLS DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7538
Practice Address - Country:US
Practice Address - Phone:978-704-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0195491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical