Healthcare Provider Details

I. General information

NPI: 1821969916
Provider Name (Legal Business Name): RYAN MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2025
Last Update Date: 09/13/2025
Certification Date: 09/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 JAMESTOWN RD STE 102
WILLIAMSBURG VA
23185-3382
US

IV. Provider business mailing address

1318 JAMESTOWN RD STE 102
WILLIAMSBURG VA
23185-3382
US

V. Phone/Fax

Practice location:
  • Phone: 757-231-5576
  • Fax: 757-834-8861
Mailing address:
  • Phone: 757-231-5576
  • Fax: 757-834-8861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0709026539
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0906017010
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: