Provider Demographics
NPI:1255950614
Name:EBERSOLE, RYAN CRAIG (PHD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:CRAIG
Last Name:EBERSOLE
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 1:2 CLARA BARTON DR # MC-164
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3472
Mailing Address - Country:US
Mailing Address - Phone:518-262-5511
Mailing Address - Fax:518-262-6111
Practice Address - Street 1:2 CLARA BARTON DR # MC-164
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3472
Practice Address - Country:US
Practice Address - Phone:518-262-5511
Practice Address - Fax:518-262-6111
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023865103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical