Provider Demographics
NPI:1497436570
Name:RYAN, KARISSA D (LMHCA)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:D
Last Name:RYAN
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 VOLL LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-3617
Mailing Address - Country:US
Mailing Address - Phone:574-520-3385
Mailing Address - Fax:
Practice Address - Street 1:611 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-3212
Practice Address - Country:US
Practice Address - Phone:574-360-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001733A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health