Provider Demographics
NPI:1154708832
Name:LEE, RYAN
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W BRADLEY PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4716
Mailing Address - Country:US
Mailing Address - Phone:773-739-5422
Mailing Address - Fax:773-409-8585
Practice Address - Street 1:2500 W BRADLEY PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4716
Practice Address - Country:US
Practice Address - Phone:773-739-5422
Practice Address - Fax:773-409-8585
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022007521363LP0808X
IL209019766363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health