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General NPI Number Information
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NPI Number | 1508401084
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Entity Type | Individual
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Provider Name | RYAN A RANDALL LCP
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Gender | Male
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Dates
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Enumeration Date | 11/08/2019
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Last Update Date | 01/10/2021
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Provider Practice Location Address
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Address Line | 1775 FORRESTAL DR BLDG 33
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City | NORFOLK
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State | VA
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Zip | 23551-0001
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Country | US
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Telephone | 757-327-1076
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Fax |
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Provider Business Mailing Address
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Address Line | 168 MARINA WYND WAY
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City | SNEADS FERRY
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State | NC
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Zip | 28460-9104
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Country | US
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Telephone | 757-327-1076
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810007248
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State | VA
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