Provider Demographics
NPI:1942351184
Name:RYAN, KIRSTEN ELISE (DT, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KIRSTEN
Middle Name:ELISE
Last Name:RYAN
Suffix:
Gender:F
Credentials:DT, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S SPRINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8139
Mailing Address - Country:US
Mailing Address - Phone:847-477-9816
Mailing Address - Fax:847-740-1749
Practice Address - Street 1:215 S SPRINGSIDE DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-8139
Practice Address - Country:US
Practice Address - Phone:847-477-9816
Practice Address - Fax:847-740-1749
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILKR42150502P222Q00000X
IL180.007497101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional