Healthcare Provider Details

I. General information

NPI: 1962038398
Provider Name (Legal Business Name): MICHELE L RYAN MA, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11565 LAUREL CANYON BLVD STE 116
SAN FERNANDO CA
91340-4650
US

IV. Provider business mailing address

23777 MULHOLLAND HWY SPC 40
CALABASAS CA
91302-3762
US

V. Phone/Fax

Practice location:
  • Phone: 818-361-5030
  • Fax:
Mailing address:
  • Phone: 702-349-0038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number118453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: