Provider Demographics
NPI:1043515521
Name:DAVIS, RYAN JAMES (LMFT, ATR)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMFT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 COVENTRY LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7579
Mailing Address - Country:US
Mailing Address - Phone:815-455-7100
Mailing Address - Fax:
Practice Address - Street 1:500 COVENTRY LN
Practice Address - Street 2:SUITE 205
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7579
Practice Address - Country:US
Practice Address - Phone:815-455-7100
Practice Address - Fax:815-455-3951
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166000811106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist