Healthcare Provider Details

I. General information

NPI: 1356544654
Provider Name (Legal Business Name): RITA RYAN RYAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BURNS AVE
LAKE WALES FL
33853-3335
US

IV. Provider business mailing address

555 BURNS AVE
LAKE WALES FL
33853-3335
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax: 863-298-0299
Mailing address:
  • Phone: 863-679-3338
  • Fax: 863-298-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW5755
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: