Provider Demographics
NPI:1194360529
Name:RYAN, LISSETTE (RBT)
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 UNIVERSITY AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0524
Mailing Address - Country:US
Mailing Address - Phone:619-403-0637
Mailing Address - Fax:619-639-8277
Practice Address - Street 1:7373 UNIVERSITY AVE STE 202
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0524
Practice Address - Country:US
Practice Address - Phone:619-403-0637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-105687106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician