Provider Demographics
NPI:1730685041
Name:RYAN-HERERERA, JANINE
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:RYAN-HERERERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1484 BRIDGEDALE RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8696
Mailing Address - Country:US
Mailing Address - Phone:815-355-4014
Mailing Address - Fax:
Practice Address - Street 1:5342 W ELM ST
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4029
Practice Address - Country:US
Practice Address - Phone:847-931-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health