Provider Demographics
NPI:1679627475
Name:WILLENS, RICHARD K (PSYD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
Last Name:WILLENS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 LOUISIANA AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2351
Mailing Address - Country:US
Mailing Address - Phone:407-629-4356
Mailing Address - Fax:407-629-1812
Practice Address - Street 1:1155 LOUISIANA AVE STE 106
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2351
Practice Address - Country:US
Practice Address - Phone:407-629-4356
Practice Address - Fax:407-629-1812
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4820103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59773AMedicare ID - Type Unspecified