Provider Demographics
NPI:1306310677
Name:MANSOURI, RYAAN J (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:RYAAN
Middle Name:J
Last Name:MANSOURI
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 POINT W
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5075
Mailing Address - Country:US
Mailing Address - Phone:765-430-8593
Mailing Address - Fax:
Practice Address - Street 1:1330 WIN HENTSCHEL BLVD STE 222
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-4160
Practice Address - Country:US
Practice Address - Phone:765-237-9091
Practice Address - Fax:765-374-2752
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007499A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical