Provider Demographics
NPI:1013657196
Name:DAVIS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DAVIS
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 1:5905 O ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2235
Mailing Address - Country:US
Mailing Address - Phone:402-890-9429
Mailing Address - Fax:
Practice Address - Street 1:5905 O ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2235
Practice Address - Country:US
Practice Address - Phone:402-436-1905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NERBT-22-233819106S00000X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider