Provider Demographics
NPI:1538192927
Name:RYAN, STACY (AUD, CCCA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:AUD, CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 N 75TH ST
Mailing Address - Street 2:WAUWATOSA
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3504
Mailing Address - Country:US
Mailing Address - Phone:414-943-3802
Mailing Address - Fax:
Practice Address - Street 1:10425 W NORTH AVE
Practice Address - Street 2:WAUWATOSA
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2416
Practice Address - Country:US
Practice Address - Phone:414-607-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI486-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41153200Medicaid
207540Medicare ID - Type Unspecified
WIK400321367Medicare PIN