Provider Demographics
NPI:1659636629
Name:RYAN, ELIZABETH (SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 MOORPARK AVE STE 117
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1804
Mailing Address - Country:US
Mailing Address - Phone:408-249-0770
Mailing Address - Fax:408-834-7767
Practice Address - Street 1:4010 MOORPARK AVE STE 117
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1804
Practice Address - Country:US
Practice Address - Phone:408-249-0770
Practice Address - Fax:408-834-7767
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 18637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP 18637Other#23 SPEECH, LANGUAGE& HEARING PROVIDERS