Provider Demographics
NPI:1538526165
Name:RYAN, KATHRYN M (LCSW)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:RYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:M
Other - Last Name:ERNST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2018
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:12 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2739
Practice Address - Country:US
Practice Address - Phone:207-701-4400
Practice Address - Fax:207-701-4487
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC149101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400292789Medicare PIN