Provider Demographics
NPI:1750047312
Name:SMITH, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SMITH
Suffix:
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 1:8663 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:MI
Mailing Address - Zip Code:49012-9265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6100 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9235
Practice Address - Country:US
Practice Address - Phone:224-908-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional