Provider Demographics
NPI:1790273027
Name:TINGLEY, RYAN JEROME (PROVISIONAL LMHC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JEROME
Last Name:TINGLEY
Suffix:
Gender:M
Credentials:PROVISIONAL LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41521 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7519 GOSHAWK AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-3573
Practice Address - Country:US
Practice Address - Phone:505-803-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NMCTB-2022-0676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician