Provider Demographics
NPI:1750047312
Name:SMITH, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SMITH
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 1:16965 HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9177
Mailing Address - Country:US
Mailing Address - Phone:224-908-8128
Mailing Address - Fax:
Practice Address - Street 1:3562 E US HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-6720
Practice Address - Country:US
Practice Address - Phone:574-372-4489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401223648101YP2500X
101YP2500X
IN99128465A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional