Healthcare Provider Details

I. General information

NPI: 1083359517
Provider Name (Legal Business Name): RYAN KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 EAGLERIDGE CIR STE 230
PUEBLO CO
81008-2176
US

IV. Provider business mailing address

4710 EAGLERIDGE CIR
PUEBLO CO
81008-2176
US

V. Phone/Fax

Practice location:
  • Phone: 719-582-8736
  • Fax: 719-434-9767
Mailing address:
  • Phone: 719-582-8736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-82484
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: