Healthcare Provider Details

I. General information

NPI: 1043055676
Provider Name (Legal Business Name): RYAN CANFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10616 PRESTON ST
WESTCHESTER IL
60154-5139
US

IV. Provider business mailing address

10616 PRESTON ST
WESTCHESTER IL
60154-5139
US

V. Phone/Fax

Practice location:
  • Phone: 708-606-9048
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180018337
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: