Provider Demographics
NPI:1306885652
Name:RYAN, ELIZABETH M (EDD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:RYAN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4829
Mailing Address - Country:US
Mailing Address - Phone:508-830-9562
Mailing Address - Fax:508-830-6735
Practice Address - Street 1:64 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4829
Practice Address - Country:US
Practice Address - Phone:508-830-9562
Practice Address - Fax:508-830-6735
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4342103T00000X
103TA0400X, 103TA0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA004343OtherTUFTS HEALTH PLAN
MAW04198Medicare ID - Type Unspecified