Provider Demographics
NPI:1649740150
Name:ELLENDER, RYAN (LMSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ELLENDER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-2715
Mailing Address - Country:US
Mailing Address - Phone:985-713-3982
Mailing Address - Fax:
Practice Address - Street 1:7855 HOWELL BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-5256
Practice Address - Country:US
Practice Address - Phone:225-475-9978
Practice Address - Fax:225-357-0795
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15948104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000000Medicaid