Provider Demographics
NPI:1679863880
Name:RYAN, SHIRLEY ANN (MS, LMHC, LMFTA)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:ANN
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS, LMHC, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6722 CANBY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1615
Mailing Address - Country:US
Mailing Address - Phone:260-402-0334
Mailing Address - Fax:
Practice Address - Street 1:2525 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5407
Practice Address - Country:US
Practice Address - Phone:260-484-4153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-10
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000067A106H00000X
IN39002614A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health