Provider Demographics
NPI:1881834604
Name:RYAN, ROBERT BRODERICK (LMHC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:BRODERICK
Last Name:RYAN
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BAYOU BLVD
Mailing Address - Street 2:SUITE 8D
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2673
Mailing Address - Country:US
Mailing Address - Phone:850-474-9881
Mailing Address - Fax:
Practice Address - Street 1:4400 BAYOU BLVD
Practice Address - Street 2:SUITE 8D
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2673
Practice Address - Country:US
Practice Address - Phone:850-474-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2270101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health