Provider Demographics
NPI:1639546005
Name:MACDONOUGH, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MACDONOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-1823
Mailing Address - Country:US
Mailing Address - Phone:860-291-1309
Mailing Address - Fax:860-291-1396
Practice Address - Street 1:281 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-1823
Practice Address - Country:US
Practice Address - Phone:860-291-1309
Practice Address - Fax:860-291-1396
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT92121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004050993Medicaid