Provider Demographics
NPI:1972812303
Name:ANDERSON, RYAN LEE
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:LEE
Last Name:ANDERSON
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 1:2901A E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-3545
Mailing Address - Country:US
Mailing Address - Phone:765-488-0859
Mailing Address - Fax:765-488-0421
Practice Address - Street 1:2901A E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-3545
Practice Address - Country:US
Practice Address - Phone:765-488-0859
Practice Address - Fax:765-488-0421
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001207A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist