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General NPI Number Information
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NPI Number | 1093223703
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Entity Type | Individual
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Provider Name | BENJAMIN RYAN JACK BCBA
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Gender | Male
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Dates
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Enumeration Date | 01/16/2018
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Last Update Date | 01/16/2018
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Provider Practice Location Address
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Address Line | 1130 TEN ROD RD STE 201
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City | NORTH KINGSTOWN
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State | RI
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Zip | 02852-4161
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Country | US
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Telephone | 401-294-3990
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Fax |
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Provider Business Mailing Address
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Address Line | 1130 TEN ROD RD STE C201 BUILDING C SUITE 201
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City | NORTH KINGSTOWN
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State | RI
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Zip | 02852-4171
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Country | US
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Telephone | 401-294-3990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-17-28975
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License Number State | RI
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