Provider Demographics
NPI:1871340687
Name:RYAN, MIKAELA
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SHAKER RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-9801
Mailing Address - Country:US
Mailing Address - Phone:207-838-1716
Mailing Address - Fax:
Practice Address - Street 1:102 CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6019
Practice Address - Country:US
Practice Address - Phone:207-777-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist