Provider Demographics
NPI:1336847458
Name:ROBERTSON, RYAN FRANCIS PAUL (BS, CCMA, CPRS, RBT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:FRANCIS PAUL
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:BS, CCMA, CPRS, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-5736
Mailing Address - Country:US
Mailing Address - Phone:931-252-9661
Mailing Address - Fax:
Practice Address - Street 1:178 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-5736
Practice Address - Country:US
Practice Address - Phone:931-252-9661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-22-222937106S00000X
TN000-1960175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist