Provider Demographics
NPI:1578058616
Name:RAGSDALE, BRYANT WAYNE (BCBA 1-16-22908)
Entity Type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:WAYNE
Last Name:RAGSDALE
Suffix:
Gender:M
Credentials:BCBA 1-16-22908
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 COOPERS COVE RD
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:VA
Mailing Address - Zip Code:24101-2505
Mailing Address - Country:US
Mailing Address - Phone:505-319-8123
Mailing Address - Fax:
Practice Address - Street 1:1609 COOPERS COVE RD
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-2505
Practice Address - Country:US
Practice Address - Phone:505-319-8123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002576103K00000X
CO1-16-22908103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA88-3694357Medicaid