Provider Demographics
NPI:1376088021
Name:DAVENPORT, RYAN TIERRA (LPCA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TIERRA
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 PROVIDENCE PLACE PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8379
Mailing Address - Country:US
Mailing Address - Phone:216-468-5000
Mailing Address - Fax:216-456-8128
Practice Address - Street 1:1255 PROVIDENCE PLACE PKWY STE 115
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-8379
Practice Address - Country:US
Practice Address - Phone:216-468-5000
Practice Address - Fax:216-456-8128
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246478101YP2500X
KY287775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid