Provider Demographics
NPI:1487148904
Name:RYAN, HOLLY D (LICSW)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:D
Last Name:RYAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 TAMARACK LN
Mailing Address - Street 2:
Mailing Address - City:WATERBURY CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05677-4415
Mailing Address - Country:US
Mailing Address - Phone:802-760-7497
Mailing Address - Fax:
Practice Address - Street 1:56 OLD FARM RD
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-4434
Practice Address - Country:US
Practice Address - Phone:802-760-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01341391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical