Basic Information
Provider Information | |||||||||
NPI: | 1760883797 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RYAN | ||||||||
FirstName: | CAITLIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26800 STILLBROOK DR | ||||||||
Address2: |   | ||||||||
City: | WESLEY CHAPEL | ||||||||
State: | FL | ||||||||
PostalCode: | 335447743 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139942214 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6508 GUNN HIGHWAY | ||||||||
Address2: | INDPENDENT LIVING, INC. | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 33625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139636923 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2014 | ||||||||
LastUpdateDate: | 09/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |   |
No ID Information.