Provider Demographics
NPI:1679618706
Name:STEVENS, RYAN SCOTT (MPS, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:SCOTT
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MPS, ATC, CSCS
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 REHILL AVE
Mailing Address - Street 2:ATTN: SPORTS PERFORMANCE & REHABILITATION CENTER
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-2519
Mailing Address - Country:US
Mailing Address - Phone:908-203-5972
Mailing Address - Fax:908-685-2413
Practice Address - Street 1:1 PATRIOTS PARK
Practice Address - Street 2:TD BANK BALLPARK
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3454
Practice Address - Country:US
Practice Address - Phone:908-203-5972
Practice Address - Fax:908-685-2413
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0013662255A2300X
NJ25MT001578002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer