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General NPI Number Information
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NPI Number | 1619672276
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Entity Type | Individual
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Provider Name | MANDI NICOLE RYAN BCBA
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Gender | Female
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Dates
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Enumeration Date | 04/03/2023
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Last Update Date | 04/03/2023
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Provider Practice Location Address
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Address Line | 1040 CLIFF GOOKIN BLVD STE H
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City | TUPELO
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State | MS
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Zip | 38801-6467
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Country | US
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Telephone | 662-205-4375
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Fax |
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Provider Business Mailing Address
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Address Line | 124 COX ST
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City | BALDWYN
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State | MS
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Zip | 38824-1509
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Country | US
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Telephone | 662-213-4191
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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 | 1-23-64591
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 220054
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License Number State | MS
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