Provider Demographics
NPI:1831203264
Name:RYAN, DORIS LOUISE (ACSW, LICSW)
Entity type:Individual
Prefix:
First Name:DORIS
Middle Name:LOUISE
Last Name:RYAN
Suffix:
Gender:F
Credentials:ACSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 CENTRAL ST
Mailing Address - Street 2:PO BOX 1245
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-4804
Mailing Address - Country:US
Mailing Address - Phone:978-870-6104
Mailing Address - Fax:978-342-8940
Practice Address - Street 1:348 LUNENBURG ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4566
Practice Address - Country:US
Practice Address - Phone:978-342-8940
Practice Address - Fax:978-342-8940
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10183681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARYP05736OtherBLUECROSS BLUE SHIELD
MARYP05736Medicare ID - Type UnspecifiedMEDICARE B