Provider Demographics
NPI:1326387994
Name:CHANDLER, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CHANDLER
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 1:2142 HERSCHEL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3820
Mailing Address - Country:US
Mailing Address - Phone:904-477-4750
Mailing Address - Fax:
Practice Address - Street 1:2142 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3820
Practice Address - Country:US
Practice Address - Phone:904-477-4750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678367868Medicaid
FL678367896Medicaid