MEDICARE: RYAN KENNEDY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	1-25-82484	CO

General Provider Information

NPI Number	:	1083359517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN KENNEDY

Provider Business Mailing Address
First Line	:	4710 EAGLERIDGE CIR
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81008-2176
Country	:	US
Telephone Number	:	719-582-8736
Fax Number	:

Provider Business Practice Location Address
First Line	:	4710 EAGLERIDGE CIR STE 230
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81008-2176
Country	:	US
Telephone Number	:	719-582-8736
Fax Number	:	719-434-9767

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2022
Last Update Date	:	07/11/2025

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Directions to “ RYAN KENNEDY ” Practice Location

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