Provider Demographics
NPI:1972835791
Name:PAGE, RYAN (MA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11369 GREENDALE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-2926
Mailing Address - Country:US
Mailing Address - Phone:586-949-6510
Mailing Address - Fax:
Practice Address - Street 1:43900 GARFIELD RD STE 222
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1137
Practice Address - Country:US
Practice Address - Phone:586-263-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012507103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist