Provider Demographics
NPI:1104406644
Name:RYAN, PAMELA A (MA, LCSW, PHD, CEA)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:A
Last Name:RYAN
Suffix:
Gender:
Credentials:MA, LCSW, PHD, CEA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MINEOLA DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1964
Mailing Address - Country:US
Mailing Address - Phone:606-356-6560
Mailing Address - Fax:
Practice Address - Street 1:102 MINEOLA DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1964
Practice Address - Country:US
Practice Address - Phone:606-356-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112436101Y00000X, 101YM0800X, 104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker