Provider Demographics
NPI:1457564908
Name:RYAN, THERESE (LISW)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VICTORIA SQ
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3406
Mailing Address - Country:US
Mailing Address - Phone:440-352-8954
Mailing Address - Fax:
Practice Address - Street 1:1 VICTORIA SQ
Practice Address - Street 2:SUITE 105
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3406
Practice Address - Country:US
Practice Address - Phone:440-352-8954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0003232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health