Provider Demographics
NPI:1871038372
Name:RYAN, TYLER MICHEAL
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:MICHEAL
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 1:19700 14 MILE RD
Mailing Address - Street 2:APARTMENT H803
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-8757
Mailing Address - Country:US
Mailing Address - Phone:517-936-3807
Mailing Address - Fax:
Practice Address - Street 1:405B S 3RD AVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-8884
Practice Address - Country:US
Practice Address - Phone:231-592-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician