Provider Demographics
NPI:1073994505
Name:RICHARDS, KENNETH W (LICENSE MASSAGE THER)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:W
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:LICENSE MASSAGE THER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-0236
Mailing Address - Country:US
Mailing Address - Phone:207-778-4990
Mailing Address - Fax:
Practice Address - Street 1:236 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-0236
Practice Address - Country:US
Practice Address - Phone:207-778-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT54225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist