Provider Demographics
NPI:1588052591
Name:RYAN, KATHRYN L
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:L
Other - Last Name:RYAN-DEVORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC
Mailing Address - Street 1:PO BOX 970872
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-0125
Mailing Address - Country:US
Mailing Address - Phone:734-931-6059
Mailing Address - Fax:
Practice Address - Street 1:1606 S HURON ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-9663
Practice Address - Country:US
Practice Address - Phone:734-931-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-27
Last Update Date:2014-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health