Provider Demographics
NPI:1154472413
Name:RYSIEW, MINOU (LCSW)
Entity Type:Individual
Prefix:
First Name:MINOU
Middle Name:
Last Name:RYSIEW
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 1:490 MAPLE FORGE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1166
Mailing Address - Country:US
Mailing Address - Phone:706-207-6611
Mailing Address - Fax:
Practice Address - Street 1:1551 JENNINGS MILL RD UNIT 3200A
Practice Address - Street 2:RESOURCE VALLEY
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7282
Practice Address - Country:US
Practice Address - Phone:706-207-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0033901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA934296907AMedicaid
GA511I800001Medicare PIN