Provider Demographics
NPI:1376609495
Name:RYAN, CHARLOTTE ANNE (LICENSED PSYCHOLOGIS)
Entity Type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ANNE
Last Name:RYAN
Suffix:
Gender:F
Credentials:LICENSED PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5019 UPTON AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2244
Mailing Address - Country:US
Mailing Address - Phone:612-801-3571
Mailing Address - Fax:612-929-9006
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-801-3571
Practice Address - Fax:612-929-9006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0096103TB0200X, 103TC0700X, 103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist