Provider Demographics
NPI:1255492609
Name:CLEMENTS, RYAN L (PSYD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:L
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 INDEPENDENCE SQ
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5150
Mailing Address - Country:US
Mailing Address - Phone:770-375-0351
Mailing Address - Fax:770-804-1241
Practice Address - Street 1:1830 INDEPENDENCE SQ
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-5150
Practice Address - Country:US
Practice Address - Phone:770-375-0351
Practice Address - Fax:770-804-1241
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002986103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist