Provider Demographics
NPI:1952791733
Name:CONWAY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CONWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4711
Mailing Address - Country:US
Mailing Address - Phone:314-520-1176
Mailing Address - Fax:
Practice Address - Street 1:900 E 7TH ST
Practice Address - Street 2:M005
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3905
Practice Address - Country:US
Practice Address - Phone:812-856-4468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)