Provider Demographics
NPI:1285647305
Name:KIRK, RICHARD B (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:KIRK
Suffix:
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:B
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:1570 WAVERLY RD
Practice Address - Street 2:HOLSTON COUNSELING SERVICES
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664
Practice Address - Country:US
Practice Address - Phone:423-224-1300
Practice Address - Fax:423-224-1375
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLCSW617104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
089854OtherANTHEM PREF TRIGON
0096965OtherMAGELLAN NAVIGATOR
13052OtherUBH HEALTHPLAN
334969OtherVALUE OPTIONS
TN3920015Medicaid
089854OtherANTHEM PROF TRIGON
0096965OtherMAGELLAN PINNACLE
0096965OtherMAGELLAN SUMMIT
TN3920247Medicaid
TN3920247Medicare ID - Type Unspecified
TN3920247Medicaid