Healthcare Provider Details

I. General information

NPI: 1760140263
Provider Name (Legal Business Name): RYLEE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 MILAN AVE E
VENICE FL
34285-2413
US

IV. Provider business mailing address

8240 LAKEWOOD RANCH BLVD UNIT 216
LAKEWOOD RANCH FL
34202-5277
US

V. Phone/Fax

Practice location:
  • Phone: 239-244-1078
  • Fax:
Mailing address:
  • Phone: 208-284-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: