Provider Demographics
NPI:1740727759
Name:RYAN, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 E BRISTOL ST STE 3-284
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-6949
Mailing Address - Country:US
Mailing Address - Phone:574-596-6404
Mailing Address - Fax:
Practice Address - Street 1:311 W HIGH ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-2827
Practice Address - Country:US
Practice Address - Phone:574-262-3597
Practice Address - Fax:574-262-3599
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-28
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015237101YP2500X
IN87001596A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional