Provider Demographics
NPI:1689233553
Name:RYAN, CAROLYN TERESA (MA, LCAT, ATR-BC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:TERESA
Last Name:RYAN
Suffix:
Gender:F
Credentials:MA, LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MALCOLM ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8023
Mailing Address - Country:US
Mailing Address - Phone:631-988-0667
Mailing Address - Fax:
Practice Address - Street 1:3 MALCOLM ST
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8023
Practice Address - Country:US
Practice Address - Phone:631-988-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002330221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002330Medicaid