Healthcare Provider Details

I. General information

NPI: 1689263899
Provider Name (Legal Business Name): KERRIE A RYAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 N OCEAN AVE
PATCHOGUE NY
11772-2016
US

IV. Provider business mailing address

31 RUSTIC AVE
MEDFORD NY
11763-4420
US

V. Phone/Fax

Practice location:
  • Phone: 631-406-9308
  • Fax:
Mailing address:
  • Phone: 631-278-9433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109722
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: