Provider Demographics
NPI:1871550434
Name:RYNEARSON, RICHARD C (PH D)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:RYNEARSON
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 DARROW RD STE 101
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1411
Mailing Address - Country:US
Mailing Address - Phone:330-650-5338
Mailing Address - Fax:330-342-3837
Practice Address - Street 1:4833 DARROW RD
Practice Address - Street 2:SUITE 101
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1411
Practice Address - Country:US
Practice Address - Phone:330-650-5338
Practice Address - Fax:330-342-3837
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH758103T00000X, 106H00000X, 103TA0700X, 103TC0700X, 103TC2200X, 103TB0200X, 103TE1100X, 103TF0000X, 103TF0200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
R71615Medicare UPIN
CP06763Medicare ID - Type Unspecified
CP06762Medicare ID - Type Unspecified