MEDICARE: RYAN EDWARDS BLACK BCBA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1376332072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN EDWARDS BLACK BCBA

Provider Business Mailing Address
First Line	:	202 S WEATHERRED DR
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-6021
Country	:	US
Telephone Number	:	214-803-1215
Fax Number	:

Provider Business Practice Location Address
First Line	:	17194 PRESTON RD STE 101
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-1203
Country	:	US
Telephone Number	:	945-218-4774
Fax Number	:

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

Provider Enumeration Date	:	05/01/2025
Last Update Date	:	05/01/2025

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