Provider Demographics
NPI:1235520180
Name:KELLY, RYAN (LCSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 ARGYLE AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1202
Mailing Address - Country:US
Mailing Address - Phone:309-531-7555
Mailing Address - Fax:708-798-2298
Practice Address - Street 1:630 ARGYLE AVE
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1202
Practice Address - Country:US
Practice Address - Phone:309-531-7555
Practice Address - Fax:708-798-2298
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490172231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical