Provider Demographics
NPI:1982733440
Name:RYAN, MIRIAM WILLIAMS (LISW)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:WILLIAMS
Last Name:RYAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:MIRIAM
Other - Middle Name:THERESA
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW/LISW
Mailing Address - Street 1:901 RIO GRANDE BLVD NW STE G252
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-2050
Mailing Address - Country:US
Mailing Address - Phone:505-226-6320
Mailing Address - Fax:
Practice Address - Street 1:901 RIO GRANDE BLVD NW STE G252
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2050
Practice Address - Country:US
Practice Address - Phone:505-702-8112
Practice Address - Fax:505-355-2611
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM 5741104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99775069Medicaid