Provider Demographics
NPI:1760556468
Name:NYBERG, RICHARD (MSW, MDIV)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:NYBERG
Suffix:
Gender:M
Credentials:MSW, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 DOVE ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3023
Mailing Address - Country:US
Mailing Address - Phone:949-222-2292
Mailing Address - Fax:949-222-0411
Practice Address - Street 1:901 DOVE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3023
Practice Address - Country:US
Practice Address - Phone:949-222-2292
Practice Address - Fax:949-222-0411
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMR 14179106H00000X
CALL75871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist