Healthcare Provider Details

I. General information

NPI: 1114551363
Provider Name (Legal Business Name): ALYSSA ELIZABETH RYAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 VICTORY BLVD
STATEN ISLAND NY
10301-2970
US

IV. Provider business mailing address

25 VICTORY BLVD
STATEN ISLAND NY
10301-2970
US

V. Phone/Fax

Practice location:
  • Phone: 646-581-3728
  • Fax:
Mailing address:
  • Phone: 646-581-3728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101447
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: