Provider Demographics
NPI:1386942159
Name:RYAN, MICHELLE SHELLEY (LISAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SHELLEY
Last Name:RYAN
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3009
Mailing Address - Country:US
Mailing Address - Phone:480-768-6022
Mailing Address - Fax:480-831-0078
Practice Address - Street 1:1745 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE 230
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3009
Practice Address - Country:US
Practice Address - Phone:480-768-6022
Practice Address - Fax:480-831-0078
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10470101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)