Provider Demographics
NPI:1073961173
Name:RICHARD, THOMAS KENNETH JR
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:KENNETH
Last Name:RICHARD
Suffix:JR
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 1:17 WEYBOSSET ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4042
Mailing Address - Country:US
Mailing Address - Phone:203-305-2861
Mailing Address - Fax:
Practice Address - Street 1:45 FAIR ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4208
Practice Address - Country:US
Practice Address - Phone:203-305-2861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1814106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist