Provider Demographics
NPI:1417746413
Name:RYAN, MARK ANTHONY (LPA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:RYAN
Suffix:
Gender:
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-4945
Mailing Address - Country:US
Mailing Address - Phone:817-726-7504
Mailing Address - Fax:
Practice Address - Street 1:3504 PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-4945
Practice Address - Country:US
Practice Address - Phone:817-726-7504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34184103TM1800X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral