Provider Demographics
NPI:1811405632
Name:MOYLAN, RYAN (MS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MOYLAN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SASSAMON AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-5816
Mailing Address - Country:US
Mailing Address - Phone:781-964-1820
Mailing Address - Fax:
Practice Address - Street 1:140 WOOD RD STE 206
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-2508
Practice Address - Country:US
Practice Address - Phone:978-222-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MA12757101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor