Healthcare Provider Details

I. General information

NPI: 1174255103
Provider Name (Legal Business Name): RYAN WATTERS LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E SUPERIOR ST STE 306
CHICAGO IL
60611-2595
US

IV. Provider business mailing address

1 E DELAWARE PL APT 28E
CHICAGO IL
60611-4986
US

V. Phone/Fax

Practice location:
  • Phone: 312-754-9404
  • Fax:
Mailing address:
  • Phone: 214-535-8529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: