Provider Demographics
NPI:1790446334
Name:RICHARDS, MARK WILLIAM
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:RICHARDS
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 1:301 LA CASA DR APT 404
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5926
Mailing Address - Country:US
Mailing Address - Phone:830-285-9140
Mailing Address - Fax:
Practice Address - Street 1:301 LA CASA DR APT 404
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5926
Practice Address - Country:US
Practice Address - Phone:830-285-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health