Provider Demographics
NPI:1699217315
Name:RYAN, KELLY ELISA (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELISA
Last Name:RYAN
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 TALMAGE CIR
Mailing Address - Street 2:STE 210
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4183
Mailing Address - Country:US
Mailing Address - Phone:651-493-8150
Mailing Address - Fax:651-493-9335
Practice Address - Street 1:3640 TALMAGE CIR
Practice Address - Street 2:STE 210
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-4183
Practice Address - Country:US
Practice Address - Phone:651-493-8150
Practice Address - Fax:651-493-9335
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1272101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional