Provider Demographics
NPI:1336953058
Name:LADA, BAILEY RYAN (RBT)
Entity type:Individual
Prefix:MR
First Name:BAILEY
Middle Name:RYAN
Last Name:LADA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:MR
Other - First Name:BAILEY
Other - Middle Name:RYAN
Other - Last Name:GADREAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3420 BRISTOL BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2240
Mailing Address - Country:US
Mailing Address - Phone:413-426-8444
Mailing Address - Fax:
Practice Address - Street 1:1831 GOLDEN EAGLE WAY
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4339
Practice Address - Country:US
Practice Address - Phone:413-426-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-402401106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician