Healthcare Provider Details

I. General information

NPI: 1356467492
Provider Name (Legal Business Name): NICOLE CHRISTINE RYAN MA, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 S CENTRAL AVE STE 205
MEDFORD OR
97501-7274
US

IV. Provider business mailing address

1015 QUEEN ANNE AVE
MEDFORD OR
97504-7048
US

V. Phone/Fax

Practice location:
  • Phone: 541-821-9559
  • Fax:
Mailing address:
  • Phone: 818-231-3137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number41776
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0790
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: