Provider Demographics
NPI:1578909107
Name:RICHARD, THEODORE III
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:RICHARD
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 1:5606 TAPIA CT
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-7474
Mailing Address - Country:US
Mailing Address - Phone:661-477-4014
Mailing Address - Fax:
Practice Address - Street 1:1932 JESSIE ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-4114
Practice Address - Country:US
Practice Address - Phone:661-395-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker