Provider Demographics
NPI:1417298548
Name:RYAN, VICTORIA (LAC, LCSW, LADC)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:LAC, LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 E PUTNAM AVE
Mailing Address - Street 2:2ND FLOOR SUITE C
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2744
Mailing Address - Country:US
Mailing Address - Phone:203-441-1228
Mailing Address - Fax:
Practice Address - Street 1:132 E PUTNAM AVE # 2C
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2744
Practice Address - Country:US
Practice Address - Phone:203-441-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT325101YA0400X
CT35841041C0700X, 1041C0700X
CT377171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes171100000XOther Service ProvidersAcupuncturist