MEDICARE: RYAN LANDVATTER

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1790491918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN LANDVATTER

Provider Business Mailing Address
First Line	:	6140 W EXECUTIVE DR STE B
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-4499
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6140 W EXECUTIVE DR STE B
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-4499
Country	:	US
Telephone Number	:	262-388-7151
Fax Number	:

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

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	01/31/2023

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Directions to “ RYAN LANDVATTER ” Practice Location

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