Healthcare Provider Details

I. General information

NPI: 1316219892
Provider Name (Legal Business Name): MOLLIE RYAN LCPC, BC-DMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5825 N ROGERS AVE APT 2
CHICAGO IL
60646-5951
US

IV. Provider business mailing address

5825 N ROGERS AVE APT 2
CHICAGO IL
60646-5951
US

V. Phone/Fax

Practice location:
  • Phone: 773-726-7290
  • Fax:
Mailing address:
  • Phone: 773-726-7290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.004000
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: