Provider Demographics
NPI:1497284228
Name:WILKERSON, RYAN (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 GYPSUM PL
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-8094
Mailing Address - Country:US
Mailing Address - Phone:904-206-7024
Mailing Address - Fax:
Practice Address - Street 1:1750 TREE BLVD STE 6
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5719
Practice Address - Country:US
Practice Address - Phone:904-206-7024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-19-38161103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020912700Medicaid