Provider Demographics
NPI:1366915860
Name:RYAN, MELISSA LEIGH
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEIGH
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 1:1902 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-0702
Mailing Address - Country:US
Mailing Address - Phone:815-592-4959
Mailing Address - Fax:
Practice Address - Street 1:8149 CASS AVE
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-5012
Practice Address - Country:US
Practice Address - Phone:630-541-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst