Healthcare Provider Details

I. General information

NPI: 1063931871
Provider Name (Legal Business Name): ANGELA K RYCKAERT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3361 36TH ST SE
GRAND RAPIDS MI
49512-2809
US

IV. Provider business mailing address

400 S VAN BUREN ST UNIT 203
STOUGHTON WI
53589-2319
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2522
  • Fax:
Mailing address:
  • Phone: 517-420-0396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401000407
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: