Provider Demographics
NPI:1417399221
Name:VAN VOORHIS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:VAN VOORHIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 W AUGUSTA BLVD
Mailing Address - Street 2:1F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4886
Mailing Address - Country:US
Mailing Address - Phone:773-297-9359
Mailing Address - Fax:
Practice Address - Street 1:2346 W AUGUSTA BLVD
Practice Address - Street 2:1F
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4886
Practice Address - Country:US
Practice Address - Phone:773-297-9359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0125541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical