Provider Demographics
NPI:1801290689
Name:OWENS, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:OWENS
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 1:1312 GUILPEN ST. NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907
Mailing Address - Country:US
Mailing Address - Phone:321-961-0356
Mailing Address - Fax:
Practice Address - Street 1:1320 CULVER DR NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1104
Practice Address - Country:US
Practice Address - Phone:321-610-3849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7126104100000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker