Provider Demographics
NPI:1093194532
Name:RYAN, CHEL'SEA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CHEL'SEA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:CHEL'SEA
Other - Middle Name:
Other - Last Name:RYAN - WATFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1110 W MONTEREY ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3562
Mailing Address - Country:US
Mailing Address - Phone:804-305-0730
Mailing Address - Fax:
Practice Address - Street 1:1101 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1808
Practice Address - Country:US
Practice Address - Phone:602-595-8145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ171201041C0700X
AZLMSW-15483104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1093194532Medicaid