Provider Demographics
NPI:1114286705
Name:RYAN, DAVID A (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:RYAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 NW FLANDERS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5410
Mailing Address - Country:US
Mailing Address - Phone:503-427-1952
Mailing Address - Fax:844-293-3937
Practice Address - Street 1:2250 NW FLANDERS ST STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5410
Practice Address - Country:US
Practice Address - Phone:503-750-1859
Practice Address - Fax:844-293-3937
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL52761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500706991Medicaid