Healthcare Provider Details

I. General information

NPI: 1740727759
Provider Name (Legal Business Name): CAROL RYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2017
Last Update Date: 08/02/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 1/2 HACKETT RD
GOSHEN IN
46528-2701
US

IV. Provider business mailing address

56878 INWOOD CT
ELKHART IN
46516-5815
US

V. Phone/Fax

Practice location:
  • Phone: 269-447-1009
  • Fax: 269-743-0118
Mailing address:
  • Phone: 269-447-1009
  • Fax: 269-743-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401015237
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001596A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: