Provider Demographics
NPI:1831343052
Name:RYAN, LISA MARIE (MA/CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:MARIE
Last Name:RYAN
Suffix:
Gender:F
Credentials:MA/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-3705
Mailing Address - Country:US
Mailing Address - Phone:845-258-0346
Mailing Address - Fax:
Practice Address - Street 1:2277 GOSHEN TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4032
Practice Address - Country:US
Practice Address - Phone:845-692-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014167-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist