Provider Demographics
NPI:1962779579
Name:RYAN, MATTHEW
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
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 1:6832 OLD DOMINION DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3887
Mailing Address - Country:US
Mailing Address - Phone:703-255-1091
Mailing Address - Fax:703-255-1091
Practice Address - Street 1:6832 OLD DOMINION DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3887
Practice Address - Country:US
Practice Address - Phone:703-255-1091
Practice Address - Fax:703-255-1091
Is Sole Proprietor?:No
Enumeration Date:2011-11-27
Last Update Date:2011-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005058101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor