Healthcare Provider Details

I. General information

NPI: 1346549466
Provider Name (Legal Business Name): MR. DEREK G. RYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 ARLINGTON BOULEVARD SUITE 110
FALLS CHURCH VA
22042-2325
US

IV. Provider business mailing address

6400 ARLINGTON BOULEVARD SUITE 110
FALLS CHURCH VA
22042-2325
US

V. Phone/Fax

Practice location:
  • Phone: 703-533-3302
  • Fax: 703-237-2083
Mailing address:
  • Phone: 703-533-3302
  • Fax: 703-237-2083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0904007429
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: