Provider Demographics
NPI:1154454809
Name:MADSEN, RICHARD BLAIR (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BLAIR
Last Name:MADSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2703
Mailing Address - Country:US
Mailing Address - Phone:719-544-0877
Mailing Address - Fax:719-544-2033
Practice Address - Street 1:417 W 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2703
Practice Address - Country:US
Practice Address - Phone:719-544-0877
Practice Address - Fax:719-544-2033
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1340103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07013402Medicaid
CO07013402Medicaid