Provider Demographics
NPI:1619122298
Name:PRIM, RICHARD CHARLES JR (MS CRP CPS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:CHARLES
Last Name:PRIM
Suffix:JR
Gender:M
Credentials:MS CRP CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W BANK ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-3279
Mailing Address - Country:US
Mailing Address - Phone:804-862-8002
Mailing Address - Fax:804-862-8023
Practice Address - Street 1:20 W BANK ST
Practice Address - Street 2:SUITE 6
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3279
Practice Address - Country:US
Practice Address - Phone:804-862-8002
Practice Address - Fax:804-862-8023
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1225094451Medicaid