=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831755388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELISSA RYAN LICSW, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2019
-----------------------------------------------------
Last Update Date | 05/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 CENTRAL ST STE 205
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02476-4816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-612-5422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 CONCORD RD
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02472-1975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-612-5422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MELISSA RYAN
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 617-612-5422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------