Provider Demographics
NPI:1013527159
Name:RYAN, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
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 1:23 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4703
Mailing Address - Country:US
Mailing Address - Phone:860-666-0786
Mailing Address - Fax:
Practice Address - Street 1:58 HIGH ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-5106
Practice Address - Country:US
Practice Address - Phone:860-496-2100
Practice Address - Fax:860-496-2111
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004322101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional