Provider Demographics
NPI:1902684046
Name:RYAN, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:RYAN
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:PO BOX 1031
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-1031
Mailing Address - Country:US
Mailing Address - Phone:406-802-0704
Mailing Address - Fax:
Practice Address - Street 1:800 KENSINGTON AVE STE 206
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5670
Practice Address - Country:US
Practice Address - Phone:406-802-0704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-44256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health