Provider Demographics
NPI:1316219892
Name:RYAN STOCK, MOLLIE (LCPC, BC-DMT)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:RYAN STOCK
Suffix:
Gender:F
Credentials:LCPC, BC-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 W ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6520
Mailing Address - Country:US
Mailing Address - Phone:773-726-7290
Mailing Address - Fax:
Practice Address - Street 1:5901 N CICERO AVE STE 606
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5721
Practice Address - Country:US
Practice Address - Phone:773-726-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.004000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1316219892Medicaid