Provider Demographics
NPI:1790364354
Name:ANON, RICHARD ALEXANDER
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALEXANDER
Last Name:ANON
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 1:23296 SW 110TH CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6299
Mailing Address - Country:US
Mailing Address - Phone:904-235-7328
Mailing Address - Fax:
Practice Address - Street 1:23296 SW 110TH CT
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6299
Practice Address - Country:US
Practice Address - Phone:904-235-7328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician