Provider Demographics
NPI:1891817201
Name:ADDISON, RICHARD B (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:ADDISON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4529
Mailing Address - Country:US
Mailing Address - Phone:707-576-9813
Mailing Address - Fax:
Practice Address - Street 1:862 3RD ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4529
Practice Address - Country:US
Practice Address - Phone:707-576-9813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9035103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist