Provider Demographics
NPI:1154097376
Name:PORTER, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PORTER
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 1:1974 NICHOLSON WALTON PIKE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051
Mailing Address - Country:US
Mailing Address - Phone:859-359-5404
Mailing Address - Fax:
Practice Address - Street 1:1974 NICHOLSON WALTON PIKE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051
Practice Address - Country:US
Practice Address - Phone:859-359-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)