Provider Demographics
NPI:1780747899
Name:PURVIS, RICHARD T (PSYD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:PURVIS
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 1:1230 S HURSTBOURNE PKWY
Mailing Address - Street 2:SUITE 245
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5757
Mailing Address - Country:US
Mailing Address - Phone:502-456-1990
Mailing Address - Fax:502-473-0667
Practice Address - Street 1:1230 S HURSTBOURNE PKWY
Practice Address - Street 2:SUITE 245
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5757
Practice Address - Country:US
Practice Address - Phone:502-456-1990
Practice Address - Fax:502-473-0667
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0935103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCP00196Medicare PIN