Provider Demographics
NPI:1639316466
Name:BLACK, RYAN DAVID (BCBA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DAVID
Last Name:BLACK
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LBA, BCBA
Mailing Address - Street 1:632 SUNRISE TRL
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:TN
Mailing Address - Zip Code:37865-3308
Mailing Address - Country:US
Mailing Address - Phone:865-985-1830
Mailing Address - Fax:423-753-6952
Practice Address - Street 1:249 OLIVER EDWARDS RD
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-6537
Practice Address - Country:US
Practice Address - Phone:423-341-7104
Practice Address - Fax:423-753-6952
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN192OtherLICENSED BEHAVIOR ANALYST
TNQ021186Medicaid