Provider Demographics
NPI:1053938746
Name:FIELDS, RYAN TYLON-ELIJAH (MHC, MPA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:TYLON-ELIJAH
Last Name:FIELDS
Suffix:
Gender:M
Credentials:MHC, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7323 210TH ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2815
Mailing Address - Country:US
Mailing Address - Phone:718-506-5457
Mailing Address - Fax:
Practice Address - Street 1:5913 GROVE ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2647
Practice Address - Country:US
Practice Address - Phone:718-506-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health