Provider Demographics
NPI:1437402518
Name:PORELL, RYAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:PORELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-5415
Mailing Address - Country:US
Mailing Address - Phone:808-282-6640
Mailing Address - Fax:
Practice Address - Street 1:800 OAKLAWN AVE
Practice Address - Street 2:B2
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-2822
Practice Address - Country:US
Practice Address - Phone:808-282-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical