Healthcare Provider Details

I. General information

NPI: 1396662839
Provider Name (Legal Business Name): RYAN REYNOLDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4870 SADLER RD STE 300
GLEN ALLEN VA
23060-6294
US

IV. Provider business mailing address

9609 SEVEN SISTERS DR
ASHLAND VA
23005-7564
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 845-702-8501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133005222
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: