Healthcare Provider Details

I. General information

NPI: 1124934955
Provider Name (Legal Business Name): RYAN KEITH MATTOCKS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 SOUTHSIDE DR STE 106
SALEM VA
24153-4684
US

IV. Provider business mailing address

1390 SOUTHSIDE DR STE 106
SALEM VA
24153-4684
US

V. Phone/Fax

Practice location:
  • Phone: 843-817-1090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701016387
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: