Provider Demographics
NPI:1225609829
Name:KNOWLES, RICHARD L
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:KNOWLES
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 1:128 SILVER BLUFF CIR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31523-8411
Mailing Address - Country:US
Mailing Address - Phone:912-242-3985
Mailing Address - Fax:
Practice Address - Street 1:106 ANDERSON WAY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1601
Practice Address - Country:US
Practice Address - Phone:912-242-3985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-174508106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician