Provider Demographics
NPI:1356925523
Name:WALTER, RYAN BLAKE
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:BLAKE
Last Name:WALTER
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 1:1325 E MALLORY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-5682
Mailing Address - Country:US
Mailing Address - Phone:850-712-4075
Mailing Address - Fax:
Practice Address - Street 1:6479 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4502
Practice Address - Country:US
Practice Address - Phone:850-607-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician