Provider Demographics
NPI:1821741471
Name:RYAN, KELLY MICHELLE (LAADC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:RYAN
Suffix:
Gender:F
Credentials:LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44359 PALM ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3116
Mailing Address - Country:US
Mailing Address - Phone:760-660-2006
Mailing Address - Fax:
Practice Address - Street 1:44359 PALM ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3116
Practice Address - Country:US
Practice Address - Phone:760-660-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCI04260315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)