Basic Information
| Provider Information | |||||||||
| NPI: | 1972836724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 MENAUL BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871071851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 LOS PADILLAS RD SW | ||||||||
| Address2: | PAJARITO ES | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871057250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058770108 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2009 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 836 | NM | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.