Provider Demographics
NPI:1023770583
Name:WEATHERS, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WEATHERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8131 RITCHIE HWY STE F
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-6940
Mailing Address - Country:US
Mailing Address - Phone:410-777-3031
Mailing Address - Fax:
Practice Address - Street 1:8131 RITCHIE HWY STE F
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6940
Practice Address - Country:US
Practice Address - Phone:410-777-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health