Basic Information
| Provider Information | |||||||||
| NPI: | 1295931400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | ROCHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 N 7TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850143654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022797655 | ||||||||
| FaxNumber: | 6022415756 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 N 95TH AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850374313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232349811 | ||||||||
| FaxNumber: | 6232349815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LAC12009 | AZ | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPC12829 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | LAC12009 | 01 | AZ | LICENSE | OTHER |