Provider Demographics
NPI:1932418183
Name:RYAN, MARY WHITNEY (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WHITNEY
Last Name:RYAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4255
Mailing Address - Country:US
Mailing Address - Phone:305-710-2877
Mailing Address - Fax:
Practice Address - Street 1:330 E LAKESIDE AVE STE B001
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2834
Practice Address - Country:US
Practice Address - Phone:208-243-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8457103TC0700X
WAPY60440889103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent