MEDICARE: KELLY ELISA RYAN MA, LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	1272	MN

General Provider Information

NPI Number	:	1699217315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ELISA RYAN MA, LPCC

Provider Business Mailing Address
First Line	:	3640 TALMAGE CIR
Second Line	:	STE 210
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-4183
Country	:	US
Telephone Number	:	651-493-8150
Fax Number	:	651-493-9335

Provider Business Practice Location Address
First Line	:	3640 TALMAGE CIR
Second Line	:	STE 210
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-4183
Country	:	US
Telephone Number	:	651-493-8150
Fax Number	:	651-493-9335

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2016
Last Update Date	:	11/11/2016

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