Provider Demographics
NPI:1659546299
Name:VANRYZIN, JUDY M
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:M
Last Name:VANRYZIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5920
Mailing Address - Country:US
Mailing Address - Phone:920-832-4741
Mailing Address - Fax:920-832-2185
Practice Address - Street 1:410 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5920
Practice Address - Country:US
Practice Address - Phone:920-832-4741
Practice Address - Fax:920-832-2185
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2487-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39279800Medicaid
WI39279800Medicaid