=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104287168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE NEUROPSYCHOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2016
-----------------------------------------------------
Last Update Date | 11/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 LAMBERT ST STE 222
-----------------------------------------------------
City | STAUNTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24401-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-886-3956
-----------------------------------------------------
Fax | 540-886-3975
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 LAMBERT ST STE 222
-----------------------------------------------------
City | STAUNTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24401-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-886-3956
-----------------------------------------------------
Fax | 540-886-3975
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | THOMAS V RYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-886-3956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810001474
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------