Provider Demographics
NPI:1871018390
Name:CARRAWAY, RICHARD MATTHEW
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MATTHEW
Last Name:CARRAWAY
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 1:117 CARLYNN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6812
Mailing Address - Country:US
Mailing Address - Phone:203-228-4208
Mailing Address - Fax:
Practice Address - Street 1:117 CARLYNN DRIVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824
Practice Address - Country:US
Practice Address - Phone:203-228-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7137363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health