Provider Demographics
NPI:1861800260
Name:HYDE, RYAN (COTA/L)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:HYDE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 W PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-8613
Mailing Address - Country:US
Mailing Address - Phone:417-872-6823
Mailing Address - Fax:
Practice Address - Street 1:2605 W PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-8613
Practice Address - Country:US
Practice Address - Phone:417-872-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014022930224Z00000X
FL18415224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant