MEDICARE: DR. RONALD W MOTLEY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1073095006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD W MOTLEY PHD

Provider Business Mailing Address
First Line	:	10836 BROADWATER DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-3007
Country	:	US
Telephone Number	:	703-591-0689
Fax Number	:

Provider Business Practice Location Address
First Line	:	10836 BROADWATER DR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22032-3007
Country	:	US
Telephone Number	:	703-591-0689
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	09/06/2018

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