Basic Information
Provider Information | |||||||||
NPI: | 1538533815 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEALE | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: | GORDON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, TLLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13343 NADINE AVE | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON WOODS | ||||||||
State: | MI | ||||||||
PostalCode: | 480701422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3125431333 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1200 N TELEGRAPH RD | ||||||||
Address2: | BUILDING 32 EAST | ||||||||
City: | PONTIAC | ||||||||
State: | MI | ||||||||
PostalCode: | 483411032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484512600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/24/2015 | ||||||||
LastUpdateDate: | 11/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301016481 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.