Provider Demographics
NPI:1982987848
Name:ANDERSON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ANDERSON
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 1:11279 PERRY HWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11279 PERRY HWY
Practice Address - Street 2:SUITE 204
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9381
Practice Address - Country:US
Practice Address - Phone:724-933-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017425103TC2200X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025287200Medicaid