Provider Demographics
NPI:1366766248
Name:RYAN, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
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 1:22 CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-4020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1563 N MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2983
Practice Address - Country:US
Practice Address - Phone:774-249-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-20
Last Update Date:2010-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor