Provider Demographics
NPI:1558119271
Name:RYAN, JUSTIN (MT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 NILES CORTLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-3869
Mailing Address - Country:US
Mailing Address - Phone:330-652-4222
Mailing Address - Fax:330-652-0574
Practice Address - Street 1:2400 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3869
Practice Address - Country:US
Practice Address - Phone:330-652-4222
Practice Address - Fax:330-652-0574
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.026852225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist