Provider Demographics
NPI:1821727959
Name:FLETCHER, RYAN ELIZABETH (MSDE)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ELIZABETH
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:MSDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 N LAWNDALE AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5302
Mailing Address - Country:US
Mailing Address - Phone:314-277-7039
Mailing Address - Fax:
Practice Address - Street 1:180 HANSEN CT
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1121
Practice Address - Country:US
Practice Address - Phone:630-595-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist