1417913757 NPI number — MICHELE DEVEREUX RYAN LCSW

Table of content: MICHELE DEVEREUX RYAN LCSW (NPI 1417913757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417913757 NPI number — MICHELE DEVEREUX RYAN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYAN
Provider First Name:
MICHELE
Provider Middle Name:
DEVEREUX
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417913757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
667B HERITAGE VLG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488-5501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-215-0795
Provider Business Mailing Address Fax Number:
203-507-2754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
437 ORANGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511-6202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-215-0795
Provider Business Practice Location Address Fax Number:
203-507-2754
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  003430 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 140003430CT02 . This is a "ABCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 182659 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P2372206 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2208920 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 182659 . This is a "MHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 165883 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".




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