Provider Demographics
NPI:1639762917
Name:MOORE, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MOORE
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 1:3410 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3042
Mailing Address - Country:US
Mailing Address - Phone:864-757-9918
Mailing Address - Fax:864-757-9921
Practice Address - Street 1:3410 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3042
Practice Address - Country:US
Practice Address - Phone:864-757-9918
Practice Address - Fax:864-757-9921
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-24-73818103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician