Provider Demographics
NPI:1073802823
Name:JIMENEZ, RICHARD (LMHC, CASAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:LMHC, CASAC
Other - Prefix:
Other - First Name:RICARDO
Other - Middle Name:
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC, CASAC
Mailing Address - Street 1:4640 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-3826
Mailing Address - Country:US
Mailing Address - Phone:716-281-0102
Mailing Address - Fax:716-989-4704
Practice Address - Street 1:4640 BROADWAY
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-3826
Practice Address - Country:US
Practice Address - Phone:716-281-0102
Practice Address - Fax:716-989-4704
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24922101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)