Provider Demographics
NPI:1164785242
Name:RYAN, NICOLE M (MASTER SOCIAL WORKER)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:RYAN
Suffix:
Gender:F
Credentials:MASTER SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 FACTORY STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:7550 SOUTH STATE STREET
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367
Practice Address - Country:US
Practice Address - Phone:315-376-5450
Practice Address - Fax:315-376-7221
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker