Provider Demographics
NPI:1528183514
Name:RYAN, LAURA NINA (LICSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:NINA
Last Name:RYAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 BILLOWS ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-1468
Mailing Address - Country:US
Mailing Address - Phone:617-539-1737
Mailing Address - Fax:
Practice Address - Street 1:839 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5710
Practice Address - Country:US
Practice Address - Phone:401-454-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW006821041C0700X
MA10175641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical