Basic Information
| Provider Information | |||||||||
| NPI: | 1629060769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1242 S 164TH AVE | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681301306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029323998 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 S 42ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025527409 | ||||||||
| FaxNumber: | 4025527497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2707 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.