Provider Demographics
NPI:1235327560
Name:RYAN, ELIZABETH JOYCE (MS)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JOYCE
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 AIRPORT BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-3168
Mailing Address - Country:US
Mailing Address - Phone:251-343-2597
Mailing Address - Fax:251-342-0112
Practice Address - Street 1:3407 SHAMROCK CT
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:228-497-1363
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid