Provider Demographics
NPI:1225554280
Name:MCDONALD, RYAN KEITH
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KEITH
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2073 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3243
Practice Address - Country:US
Practice Address - Phone:321-888-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician