Provider Demographics
NPI:1942719638
Name:RYAN, MARK CONLEY (RADT-1)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CONLEY
Last Name:RYAN
Suffix:
Gender:M
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 ROAN RANCH CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4614
Mailing Address - Country:US
Mailing Address - Phone:619-218-8609
Mailing Address - Fax:
Practice Address - Street 1:3800 POWER INN RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-4333
Practice Address - Country:US
Practice Address - Phone:916-450-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1257170717101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)