Provider Demographics
NPI:1619066446
Name:RYAN, KRISTEN ANN (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:ANN
Last Name:RYAN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 PILLSBURY AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-1542
Mailing Address - Country:US
Mailing Address - Phone:612-695-0470
Mailing Address - Fax:612-824-4381
Practice Address - Street 1:190 5TH ST E
Practice Address - Street 2:STE. 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2666
Practice Address - Country:US
Practice Address - Phone:651-389-4677
Practice Address - Fax:651-389-4690
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4444103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN158103100Medicare ID - Type UnspecifiedPROVIDER NUMBER