Basic Information
| Provider Information | |||||||||
| NPI: | 1306290556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | TILMAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 873 SE WILLIAMS CT | ||||||||
| Address2: | |||||||||
| City: | WAUKEE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502638351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152053731 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 945 19TH ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503141117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152410982 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 04/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 05641 | IA | Y | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 05641 | IA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.