Provider Demographics
NPI:1487465795
Name:MIZOGUCHI, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MIZOGUCHI
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 1:11500 S EASTERN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5576
Mailing Address - Country:US
Mailing Address - Phone:856-760-0607
Mailing Address - Fax:
Practice Address - Street 1:11500 S EASTERN AVE STE 150
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5576
Practice Address - Country:US
Practice Address - Phone:856-760-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT4955106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician