Basic Information
| Provider Information | |||||||||
| NPI: | 1962655910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | LOGAN | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 ROHLWING RD | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475248800 | ||||||||
| FaxNumber: | 8475248824 | ||||||||
| Practice Location | |||||||||
| Address1: | 852 S WEST ST | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605406400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303055122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 071.008948 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.