Healthcare Provider Details

I. General information

NPI: 1588032551
Provider Name (Legal Business Name): RYAN GALVIN PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/02/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 INNOVATION DRIVE SUITE LL20
FAIRFAX VA
22031
US

IV. Provider business mailing address

1050 N STUART ST APT 809
ARLINGTON VA
22201-5750
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-0490
  • Fax:
Mailing address:
  • Phone: 703-819-8875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number2305215369
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: