Provider Demographics
NPI:1184357659
Name:RYAN, MACKENZY (OTR/L)
Entity type:Individual
Prefix:
First Name:MACKENZY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SUTULA RD
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-2265
Mailing Address - Country:US
Mailing Address - Phone:914-819-8046
Mailing Address - Fax:
Practice Address - Street 1:2 SUTULA RD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2265
Practice Address - Country:US
Practice Address - Phone:914-819-8046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-02
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12922225X00000X
CT004992225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
402411OtherNBCOT CERTIFICATION #