Provider Demographics
NPI:1265521736
Name:OFFUTT, RICHARD A (PSYD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:OFFUTT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 SOUTH COBB DR
Mailing Address - Street 2:#115
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:770-431-2354
Mailing Address - Fax:770-436-7143
Practice Address - Street 1:4015 SOUTH COBB DR
Practice Address - Street 2:#115
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:770-431-2354
Practice Address - Fax:770-436-7143
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001343103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R70951Medicare UPIN
68BBCSVMedicare ID - Type Unspecified