Provider Demographics
NPI:1174255103
Name:WATTERS, RYAN (LSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WATTERS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E DELAWARE PL APT 28E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4986
Mailing Address - Country:US
Mailing Address - Phone:214-535-8529
Mailing Address - Fax:
Practice Address - Street 1:1 E SUPERIOR ST STE 306
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2595
Practice Address - Country:US
Practice Address - Phone:312-754-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical