Provider Demographics
NPI:1619256914
Name:ITZCOVICH SCHUSTER, RYAN MICHAEL
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:ITZCOVICH SCHUSTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:MICHAEL
Other - Last Name:SCHUSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4106 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-2535
Mailing Address - Country:US
Mailing Address - Phone:213-259-3156
Mailing Address - Fax:
Practice Address - Street 1:4106 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-2535
Practice Address - Country:US
Practice Address - Phone:213-259-3156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29137103TC0700X
390200000X
WA61117866103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY29137OtherPSYCHOLOGIST LICENSE