Provider Demographics
NPI:1346549466
Name:RYAN, DEREK G
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:G
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 ARLINGTON BOULEVARD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-2325
Mailing Address - Country:US
Mailing Address - Phone:703-533-3302
Mailing Address - Fax:703-237-2083
Practice Address - Street 1:6400 ARLINGTON BOULEVARD
Practice Address - Street 2:SUITE 110
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-2325
Practice Address - Country:US
Practice Address - Phone:703-533-3302
Practice Address - Fax:703-237-2083
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904007429104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker