Provider Demographics
NPI:1669770061
Name:NIELSEN, RICHARD MILLS III
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MILLS
Last Name:NIELSEN
Suffix:III
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:MILLS
Other - Last Name:NIELSEN
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:LBSW
Mailing Address - Street 1:12800 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2061
Mailing Address - Country:US
Mailing Address - Phone:313-824-8000
Mailing Address - Fax:313-824-5589
Practice Address - Street 1:12800 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2061
Practice Address - Country:US
Practice Address - Phone:313-824-8000
Practice Address - Fax:313-824-5589
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020799521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802079952Medicaid