Provider Demographics
NPI:1730701103
Name:RYAN, KEVIN M
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
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 1:605 W OXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-1208
Mailing Address - Country:US
Mailing Address - Phone:580-233-7220
Mailing Address - Fax:
Practice Address - Street 1:605 W OXFORD AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-1208
Practice Address - Country:US
Practice Address - Phone:580-233-7220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health