Provider Demographics
NPI:1184216616
Name:SMITH, RYAN DALE
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 E BIDWELL ST # 100680
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6480
Mailing Address - Country:US
Mailing Address - Phone:916-494-8472
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 185
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5006
Practice Address - Country:US
Practice Address - Phone:916-494-8472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-21-161319106S00000X
1-23-69995103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician