MEDICARE: RYAN DESLAURIERS RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1376075002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN DESLAURIERS RBT

Provider Business Mailing Address
First Line	:	12235 BEACH BLVD STE 110
Second Line	:
City	:	STANTON
State	:	CA
Zip	:	90680-3943
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12235 BEACH BLVD STE 110
Second Line	:
City	:	STANTON
State	:	CA
Zip	:	90680-3943
Country	:	US
Telephone Number	:	760-468-7988
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2017
Last Update Date	:	07/14/2021

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