Provider Demographics
NPI:1639599459
Name:RYAN, MARY BETH (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
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 1:630 SHERIDAN SQ
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4747
Mailing Address - Country:US
Mailing Address - Phone:708-772-1440
Mailing Address - Fax:
Practice Address - Street 1:630 SHERIDAN SQ
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-4747
Practice Address - Country:US
Practice Address - Phone:708-772-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490156961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical