Provider Demographics
NPI:1437504487
Name:AUSTIN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:AUSTIN
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 1:1354 8TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-1812
Mailing Address - Country:US
Mailing Address - Phone:540-342-4048
Mailing Address - Fax:540-342-5395
Practice Address - Street 1:1354 8TH ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-1812
Practice Address - Country:US
Practice Address - Phone:540-342-4048
Practice Address - Fax:540-342-5395
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA69770426101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor