Healthcare Provider Details

I. General information

NPI: 1669800769
Provider Name (Legal Business Name): DR. RYAN BODDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9047 EXECUTIVE PARK DR STE 210
KNOXVILLE TN
37923-4625
US

IV. Provider business mailing address

9047 EXECUTIVE PARK DR STE 210
KNOXVILLE TN
37923-4625
US

V. Phone/Fax

Practice location:
  • Phone: 865-684-8034
  • Fax:
Mailing address:
  • Phone: 865-684-8034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3221
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3221
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: