Provider Demographics
NPI:1740717305
Name:EDWARDS, RYAN NICKOLAS (NONE)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:NICKOLAS
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 W BELDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3223
Mailing Address - Country:US
Mailing Address - Phone:630-656-4853
Mailing Address - Fax:
Practice Address - Street 1:600 ENTERPRISE DR STE 220
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523
Practice Address - Country:US
Practice Address - Phone:844-632-7736
Practice Address - Fax:888-972-3621
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
IL178.014360101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health