Provider Demographics
NPI:1609401165
Name:RICHARD, JONATHAN DAVID (LPC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:RICHARD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:DAVID
Other - Last Name:RICHARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:108 WILD BASIN RD STE 250
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-3468
Mailing Address - Country:US
Mailing Address - Phone:512-399-3001
Mailing Address - Fax:
Practice Address - Street 1:108 WILD BASIN RD STE 250
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-3468
Practice Address - Country:US
Practice Address - Phone:512-399-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor