Provider Demographics
NPI:1083925275
Name:RYAN, MOLLY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N BENJAMIN LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5094
Mailing Address - Country:US
Mailing Address - Phone:904-553-5017
Mailing Address - Fax:
Practice Address - Street 1:6360 CHRISTOPHER CREEK RD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2472
Practice Address - Country:US
Practice Address - Phone:904-553-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4907101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor