Provider Demographics
NPI:1477911428
Name:RYAN, LISA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 CATHEDRAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:WV
Mailing Address - Zip Code:26705-8217
Mailing Address - Country:US
Mailing Address - Phone:304-698-4567
Mailing Address - Fax:
Practice Address - Street 1:31452 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TERRA ALTA
Practice Address - State:WV
Practice Address - Zip Code:26764-9715
Practice Address - Country:US
Practice Address - Phone:304-789-1029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1092103TC0700X
MD05746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist