Provider Demographics
NPI:1760851224
Name:RYAN, ROBERT KEVIN
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KEVIN
Last Name:RYAN
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:PO BOX 6041
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90264-6041
Mailing Address - Country:US
Mailing Address - Phone:310-924-0273
Mailing Address - Fax:
Practice Address - Street 1:28310 ROADSIDE DRIVE SUITE 235
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301
Practice Address - Country:US
Practice Address - Phone:310-924-0273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT85893101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health