Provider Demographics
NPI:1265259907
Name:RYAN, ILONA CASEY
Entity type:Individual
Prefix:
First Name:ILONA
Middle Name:CASEY
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3231 WILLAMETTE DR NE STE A
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-1378
Mailing Address - Country:US
Mailing Address - Phone:253-455-4625
Mailing Address - Fax:
Practice Address - Street 1:2584 RW JOHNSON BOULEVVARD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512
Practice Address - Country:US
Practice Address - Phone:360-878-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61608420106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician