Provider Demographics
NPI:1962040329
Name:JOHNSON, RYAN LEE (BCBA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 WAR EAGLE DR N
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1650
Mailing Address - Country:US
Mailing Address - Phone:605-951-1293
Mailing Address - Fax:
Practice Address - Street 1:5446 N ACADEMY BLVD STE 105
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3668
Practice Address - Country:US
Practice Address - Phone:719-598-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-21-51614103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician