Provider Demographics
NPI:1114317278
Name:RYAN, AVERY (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E BROAD ST, 4TH FLOOR
Mailing Address - Street 2:BOX 980142
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219
Mailing Address - Country:US
Mailing Address - Phone:804-828-0431
Mailing Address - Fax:
Practice Address - Street 1:1000 E BROAD ST FL 4
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1930
Practice Address - Country:US
Practice Address - Phone:804-828-0431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202009065235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist