Provider Demographics
NPI:1225657083
Name:BLANKSON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BLANKSON
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 1:6074 SECRECT ISLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-0551
Mailing Address - Country:US
Mailing Address - Phone:702-465-0657
Mailing Address - Fax:
Practice Address - Street 1:6074 SECRET ISLAND DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-6250
Practice Address - Country:US
Practice Address - Phone:702-465-0657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty