Provider Demographics
NPI:1528578663
Name:BALDWIN, RICHARD III
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BALDWIN
Suffix:III
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 1:4292 TRILLIUM WOOD TRL
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-6087
Mailing Address - Country:US
Mailing Address - Phone:404-423-9804
Mailing Address - Fax:
Practice Address - Street 1:4292 TRILLIUM WOOD TRL
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-6087
Practice Address - Country:US
Practice Address - Phone:404-423-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid