Provider Demographics
NPI:1972199362
Name:RYAN, SHANE ROBERT
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ROBERT
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 1:2280 DIAMOND BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5719
Mailing Address - Country:US
Mailing Address - Phone:925-759-7542
Mailing Address - Fax:
Practice Address - Street 1:2280 DIAMOND BLVD STE 500
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5719
Practice Address - Country:US
Practice Address - Phone:925-482-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health