Provider Demographics
NPI:1760807051
Name:BEATTY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BEATTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 W 40TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-7148
Mailing Address - Country:US
Mailing Address - Phone:818-429-8975
Mailing Address - Fax:
Practice Address - Street 1:457 W 40TH ST APT B
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-7148
Practice Address - Country:US
Practice Address - Phone:818-429-8975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 71833101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health