Healthcare Provider Details

I. General information

NPI: 1508336041
Provider Name (Legal Business Name): SHANE RONAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7551 FREEPORT BLVD # 1019
SACRAMENTO CA
95832-1001
US

IV. Provider business mailing address

4221 WILSHIRE BLVD STE 300
LOS ANGELES CA
90010-3512
US

V. Phone/Fax

Practice location:
  • Phone: 888-428-3223
  • Fax:
Mailing address:
  • Phone: 888-428-3223
  • Fax: 323-866-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberRBT-18-73576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: