Provider Demographics
NPI:1801856067
Name:LEE, RYAN (OT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:3218 DAUGHERTY DR STE 160
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-4402
Practice Address - Country:US
Practice Address - Phone:765-477-6464
Practice Address - Fax:765-477-6262
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003989A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000319250OtherANTHEM PROVIDER NUMBER
IN200476540Medicaid
IN200476540Medicaid