Provider Demographics
NPI:1659076073
Name:MATTIOLI, RYAN PETER
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PETER
Last Name:MATTIOLI
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 1:72006 GA HIGHWAY 46 E # C-13
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-6143
Mailing Address - Country:US
Mailing Address - Phone:312-483-8680
Mailing Address - Fax:
Practice Address - Street 1:332 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0714
Practice Address - Country:US
Practice Address - Phone:912-243-9429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017880101YM0800X
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health