Provider Demographics
NPI:1235155052
Name:RYAN, NICOLET KIM (LISW-CP)
Entity type:Individual
Prefix:
First Name:NICOLET
Middle Name:KIM
Last Name:RYAN
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31738
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-0029
Mailing Address - Country:US
Mailing Address - Phone:843-855-0035
Mailing Address - Fax:
Practice Address - Street 1:100 SUTTER DR
Practice Address - Street 2:SUITE 305
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-8665
Practice Address - Country:US
Practice Address - Phone:843-855-0035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical