Provider Demographics
NPI:1083852164
Name:RYAN, MARY LORAINE
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LORAINE
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 1:411 E CONGRESS PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6247
Mailing Address - Country:US
Mailing Address - Phone:815-459-3810
Mailing Address - Fax:815-356-3550
Practice Address - Street 1:411 E CONGRESS PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6247
Practice Address - Country:US
Practice Address - Phone:815-459-3810
Practice Address - Fax:815-356-3550
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.000176224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant