Provider Demographics
NPI:1508401084
Name:RANDALL, RYAN A (LCP)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:A
Last Name:RANDALL
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 MARINA WYND WAY
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-9104
Mailing Address - Country:US
Mailing Address - Phone:757-327-1076
Mailing Address - Fax:
Practice Address - Street 1:1775 FORRESTAL DR BLDG 33
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23551-0001
Practice Address - Country:US
Practice Address - Phone:757-327-1076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007248103TC0700X
VA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist