MEDICARE: MRS. KIRSTEN ELISE RYAN DT, LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist	KR42150502P	IL
2	101YP2500X	Professional Counselor	180.007497	IL

General Provider Information

NPI Number	:	1942351184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIRSTEN ELISE RYAN DT, LCPC

Provider Business Mailing Address
First Line	:	215 S SPRINGSIDE DR
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-8139
Country	:	US
Telephone Number	:	847-477-9816
Fax Number	:	847-740-1749

Provider Business Practice Location Address
First Line	:	215 S SPRINGSIDE DR
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-8139
Country	:	US
Telephone Number	:	847-477-9816
Fax Number	:	847-740-1749

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	11/11/2010

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