Provider Demographics
NPI:1275709826
Name:RICHARDSON, CLYDE A (M DIV CAC-R)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:A
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:M DIV CAC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 EAGLE RUN DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-957-1200
Mailing Address - Fax:616-957-1297
Practice Address - Street 1:3210 EAGLE RUN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-957-1200
Practice Address - Fax:616-957-1297
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802067415101YA0400X, 101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE