Provider Demographics
NPI:1679055966
Name:BLUE, RYAN (OTR)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BLUE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 OLD SAN ANTONIO RD # 8308
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-3415
Mailing Address - Country:US
Mailing Address - Phone:817-565-9373
Mailing Address - Fax:
Practice Address - Street 1:1213 WATER ST
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-3543
Practice Address - Country:US
Practice Address - Phone:830-896-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118949225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty