Provider Demographics
NPI:1417913757
Name:RYAN, MICHELE DEVEREUX (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:DEVEREUX
Last Name:RYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667B HERITAGE VLG
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-5501
Mailing Address - Country:US
Mailing Address - Phone:203-215-0795
Mailing Address - Fax:203-507-2754
Practice Address - Street 1:437 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6202
Practice Address - Country:US
Practice Address - Phone:203-215-0795
Practice Address - Fax:203-507-2754
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0034301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
140003430CT02OtherABCBS
182659OtherMAGELLAN
P2372206OtherOXFORD
2208920OtherCIGNA
182659OtherMHN
165883OtherVALUE OPTIONS
P53571Medicare UPIN