Healthcare Provider Details

I. General information

NPI: 1215690847
Provider Name (Legal Business Name): RYAN DEROUIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 7TH ST
CHARLOTTE NC
28204-6300
US

IV. Provider business mailing address

PO BOX 8544
PASADENA CA
91109-8602
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-4171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: