Provider Demographics
NPI:1104222975
Name:RYAN, LINDA (LCSW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CORPORATE PARK DR APT 3050
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10604-3331
Mailing Address - Country:US
Mailing Address - Phone:914-873-1087
Mailing Address - Fax:
Practice Address - Street 1:105 CORPORATE PARK DR
Practice Address - Street 2:#3050
Practice Address - City:WEST HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10604-3331
Practice Address - Country:US
Practice Address - Phone:914-873-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY093175-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02449154OtherMEDICAID #
NY1285628552OtherAGENCY
NYWVE061OtherMEDICARE #