Basic Information
| Provider Information | |||||||||
| NPI: | 1063749570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 COMMONWEALTH | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005255188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 05/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 6301013674 | MI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 6301013674 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.