Healthcare Provider Details

I. General information

NPI: 1447604285
Provider Name (Legal Business Name): RYAN COVENTRY M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 N CLARK ST SUITE 212
CHICAGO IL
60640-2120
US

IV. Provider business mailing address

4610 N CLARK ST # 1037
CHICAGO IL
60640-4620
US

V. Phone/Fax

Practice location:
  • Phone: 312-600-5491
  • Fax:
Mailing address:
  • Phone: 312-741-3320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.011581
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.011972
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.011581
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011972
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: