=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740717305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN NICKOLAS EDWARDS NONE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2017
-----------------------------------------------------
Last Update Date | 01/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 ENTERPRISE DR STE 220
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-632-7736
-----------------------------------------------------
Fax | 888-972-3621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2334 W BELDEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-656-4853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 178.014360
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------