Provider Demographics
NPI:1356780332
Name:RYAN, MADELEINE R (MSW)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:R
Last Name:RYAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26520 BERG RD
Mailing Address - Street 2:APT 614
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-5398
Mailing Address - Country:US
Mailing Address - Phone:901-351-7825
Mailing Address - Fax:
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-831-5535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-23
Last Update Date:2013-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010946251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical