Provider Demographics
NPI:1376015446
Name:ILLAN, RYANN M (CG60906357)
Entity Type:Individual
Prefix:
First Name:RYANN
Middle Name:M
Last Name:ILLAN
Suffix:
Gender:F
Credentials:CG60906357
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S LANE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2810
Mailing Address - Country:US
Mailing Address - Phone:206-682-2371
Mailing Address - Fax:
Practice Address - Street 1:1600 S LANE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2810
Practice Address - Country:US
Practice Address - Phone:206-682-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-29
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60906357101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health