Healthcare Provider Details

I. General information

NPI: 1669030318
Provider Name (Legal Business Name): MR. RYAN WOMACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 W DEVON AVE
CHICAGO IL
60660-1344
US

IV. Provider business mailing address

1542 W DEVON AVE
CHICAGO IL
60660-1344
US

V. Phone/Fax

Practice location:
  • Phone: 773-465-4600
  • Fax:
Mailing address:
  • Phone: 614-987-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162437
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.028701
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2304483
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: