Provider Demographics
NPI:1720017171
Name:RYAN, SUSAN (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 SECOND AVENUE, BLDG. C, SUITE 650
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426
Mailing Address - Country:US
Mailing Address - Phone:610-306-4774
Mailing Address - Fax:
Practice Address - Street 1:555 SECOND AVENUE, BLDG. C, SUITE 650
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426
Practice Address - Country:US
Practice Address - Phone:610-306-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3024103T00000X
PAPSO15316103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist