MEDICARE: MR. RYAN KECK BCBA

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	103K00000X	Behavior Analyst	1-21-53997	FL

General Provider Information

NPI Number	:	1912543869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN KECK BCBA

Provider Business Mailing Address
First Line	:	2404 RUTH HENTZ AVE BLDG B
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2404 RUTH HENTZ AVE BLDG B
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2258
Country	:	US
Telephone Number	:	850-628-1713
Fax Number	:

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

Provider Enumeration Date	:	11/25/2019
Last Update Date	:	10/12/2021

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