Provider Demographics
NPI:1538480256
Name:MAILLY, RYAN JAMES (LCSW)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JAMES
Last Name:MAILLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 ARMSTRONG ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5702
Mailing Address - Country:US
Mailing Address - Phone:858-569-3940
Mailing Address - Fax:
Practice Address - Street 1:3002 ARMSTRONG ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5702
Practice Address - Country:US
Practice Address - Phone:858-569-3940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27948101YM0800X
CA293951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health