Provider Demographics
NPI:1790021806
Name:STANDIFER, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:STANDIFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 CESARIO DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9051
Mailing Address - Country:US
Mailing Address - Phone:847-792-6040
Mailing Address - Fax:
Practice Address - Street 1:500 COVENTRY LN
Practice Address - Street 2:SUITE 170
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7579
Practice Address - Country:US
Practice Address - Phone:815-356-2700
Practice Address - Fax:815-356-2709
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009043225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist