Healthcare Provider Details

I. General information

NPI: 1538434790
Provider Name (Legal Business Name): KELLY MARIE RYAN MLADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 CYPRESS ST STE 8
MANCHESTER NH
03103-3600
US

IV. Provider business mailing address

445 CYPRESS ST STE 8
MANCHESTER NH
03103-3600
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-4079
  • Fax: 603-663-8605
Mailing address:
  • Phone: 603-668-4079
  • Fax: 603-663-8605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0989
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: