Provider Demographics
NPI:1780082701
Name:MATTEK, RYAN J (PHD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
Last Name:MATTEK
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 1:6650 W STATE ST
Mailing Address - Street 2:SUITE 156
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2827
Mailing Address - Country:US
Mailing Address - Phone:414-491-0854
Mailing Address - Fax:
Practice Address - Street 1:6650 W STATE ST
Practice Address - Street 2:SUITE 156
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2827
Practice Address - Country:US
Practice Address - Phone:414-491-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3229-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist