Healthcare Provider Details

I. General information

NPI: 1982533469
Provider Name (Legal Business Name): RILEY BRAGG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 W MOUND ST
COLUMBUS OH
43223-2018
US

IV. Provider business mailing address

1494 ASCHINGER BLVD
COLUMBUS OH
43212-4612
US

V. Phone/Fax

Practice location:
  • Phone: 614-365-5968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.02170
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: