Provider Demographics
NPI:1972665362
Name:RYAN, KELLIE MARIA
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:MARIA
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 1:233 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876
Mailing Address - Country:US
Mailing Address - Phone:978-851-9762
Mailing Address - Fax:
Practice Address - Street 1:148 WARREN ST
Practice Address - Street 2:EI SO BAY MENTAL HEALTH
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-452-1736
Practice Address - Fax:978-452-6625
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program