Provider Demographics
NPI:1396838983
Name:RICHARDS, KEVIN J (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:RICHARDS
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 1:199 FRASIER ST SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2201
Mailing Address - Country:US
Mailing Address - Phone:678-310-3442
Mailing Address - Fax:678-564-4401
Practice Address - Street 1:199 FRASIER ST SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2201
Practice Address - Country:US
Practice Address - Phone:678-310-3442
Practice Address - Fax:678-564-4401
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002508103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000950441AMedicaid