Basic Information
| Provider Information | |||||||||
| NPI: | 1679618706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPS, ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 REHILL AVE | ||||||||
| Address2: | ATTN: SPORTS PERFORMANCE & REHABILITATION CENTER | ||||||||
| City: | SOMERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088762519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082035972 | ||||||||
| FaxNumber: | 9086852413 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PATRIOTS PARK | ||||||||
| Address2: | TD BANK BALLPARK | ||||||||
| City: | BRIDGEWATER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088073454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082035972 | ||||||||
| FaxNumber: | 9086852413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
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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 | 2255A2300X | 001366 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 25MT00157800 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.