Provider Demographics
NPI:1629122544
Name:RYAN, WILLIAM BERNARD (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BERNARD
Last Name:RYAN
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 1:1648 ELLIS ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-586-9580
Mailing Address - Fax:406-587-1513
Practice Address - Street 1:1648 ELLIS ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-586-9580
Practice Address - Fax:406-587-1513
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT219103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0492232Medicaid
MT52920OtherBLUE CROSS
MT52920OtherBLUE CROSS