Provider Demographics
NPI:1962655910
Name:RYAN, KELLY LOGAN (PSYD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LOGAN
Last Name:RYAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 ROHLWING RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3217
Mailing Address - Country:US
Mailing Address - Phone:847-524-8800
Mailing Address - Fax:847-524-8824
Practice Address - Street 1:852 S WEST ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6400
Practice Address - Country:US
Practice Address - Phone:630-305-5122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL071.008948103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health