Provider Demographics
NPI:1336294891
Name:RICHIE, DAVID MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:RICHIE
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:PO BOX 690121
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78269-0121
Mailing Address - Country:US
Mailing Address - Phone:210-614-5563
Mailing Address - Fax:210-616-0785
Practice Address - Street 1:23029 S FORK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78255-2105
Practice Address - Country:US
Practice Address - Phone:210-614-5563
Practice Address - Fax:210-616-0785
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22993103G00000X, 103T00000X, 103TR0400X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00GK60OtherMEDICARE PTAN
TXR57790Medicare UPIN