Provider Demographics
NPI:1679030589
Name:RYAN, MARYKATE (MA)
Entity Type:Individual
Prefix:
First Name:MARYKATE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 HORY ST
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-3243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:431 CRANBURY RD
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3698
Practice Address - Country:US
Practice Address - Phone:888-951-8687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00982100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty