Provider Demographics
NPI:1306171194
Name:RYAN, MARK ALLEN (MA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:RYAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-4444
Mailing Address - Country:US
Mailing Address - Phone:406-498-5836
Mailing Address - Fax:
Practice Address - Street 1:3242 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-4444
Practice Address - Country:US
Practice Address - Phone:406-498-5836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1365101Y00000X
MO002638101YP2500X
MO300130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist