Provider Demographics
NPI:1205327301
Name:RYAN, SEAN (PHD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4039
Mailing Address - Country:US
Mailing Address - Phone:401-440-4954
Mailing Address - Fax:
Practice Address - Street 1:20 ADMIN RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-3230
Practice Address - Country:US
Practice Address - Phone:508-279-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3628103T00000X
MA10378103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10378OtherPSYCHOLOGY LICENSE
CT3628OtherPSYCHOLOGY LICENSE