Provider Demographics
NPI:1043576192
Name:TYLER PORTIS, EBONY (BHS)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:TYLER PORTIS
Suffix:
Gender:F
Credentials:BHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 NE 36TH ST STE 100G
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-5218
Mailing Address - Country:US
Mailing Address - Phone:405-270-0005
Mailing Address - Fax:
Practice Address - Street 1:1900 NE 36TH ST STE 100G
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-5218
Practice Address - Country:US
Practice Address - Phone:405-270-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional