Provider Demographics
NPI:1871091090
Name:GOSS, RYAN TERRY
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:TERRY
Last Name:GOSS
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 1:1855 W HIBISCUS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2622
Mailing Address - Country:US
Mailing Address - Phone:321-265-4409
Mailing Address - Fax:321-765-4232
Practice Address - Street 1:1855 W HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2622
Practice Address - Country:US
Practice Address - Phone:321-265-4409
Practice Address - Fax:321-765-4232
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician