Provider Demographics
NPI:1215512660
Name:RYAN, KELLY MARJORIE (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARJORIE
Last Name:RYAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 E BELVIDERE RD
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2012
Mailing Address - Country:US
Mailing Address - Phone:847-535-8817
Mailing Address - Fax:
Practice Address - Street 1:1475 E BELVIDERE RD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2012
Practice Address - Country:US
Practice Address - Phone:847-535-8817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist