Provider Demographics
NPI:1538533815
Name:BEALE, RYAN GORDON (MA, TLLP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:GORDON
Last Name:BEALE
Suffix:
Gender:M
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13343 NADINE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1422
Mailing Address - Country:US
Mailing Address - Phone:312-543-1333
Mailing Address - Fax:
Practice Address - Street 1:1200 N TELEGRAPH RD
Practice Address - Street 2:BUILDING 32 EAST
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1032
Practice Address - Country:US
Practice Address - Phone:248-451-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016481103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical