Healthcare Provider Details

I. General information

NPI: 1134584865
Provider Name (Legal Business Name): RYAN A SELBERG BCBA, LBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 N EUSTIS ST
EUSTIS FL
32726-3408
US

IV. Provider business mailing address

16601 STATE ROUTE 9 SE APT A
SNOHOMISH WA
98296-6313
US

V. Phone/Fax

Practice location:
  • Phone: 321-436-9792
  • Fax: 888-719-7820
Mailing address:
  • Phone: 360-710-9204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-15-01871
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA61057756
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: