Basic Information
| Provider Information | |||||||||
| NPI: | 1386942159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | SHELLEY | ||||||||
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| Credential: | LISAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1745 S ALMA SCHOOL RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807686022 | ||||||||
| FaxNumber: | 4808310078 | ||||||||
| Practice Location | |||||||||
| Address1: | 1745 S ALMA SCHOOL RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807686022 | ||||||||
| FaxNumber: | 4808310078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2011 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-10470 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.