Basic Information
| Provider Information | |||||||||
| NPI: | 1588003263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 585 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016051906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088310045 | ||||||||
| FaxNumber: | 5087535051 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016051906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088310045 | ||||||||
| FaxNumber: | 5087535051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1308785 | 05 | MA | MEDICAID | 22220002001 | 01 | MA | BLUE CROSS BLUE SHEILD | OTHER | M18684 | 01 | MA | BLUE CROSS BLUE SHEILD | OTHER | 1306461 | 05 | MA | MEDICAID |