Provider Demographics
NPI:1073966396
Name:GROENEWEG, RYAN (EDS, BCBA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GROENEWEG
Suffix:
Gender:M
Credentials:EDS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:IA
Mailing Address - Zip Code:51201-1243
Mailing Address - Country:US
Mailing Address - Phone:712-324-5417
Mailing Address - Fax:
Practice Address - Street 1:330 VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1243
Practice Address - Country:US
Practice Address - Phone:712-324-5417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1-10-6842103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst