Provider Demographics
NPI:1831625102
Name:HALLIBURTON, RICHARD PERRY (PSYD)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:PERRY
Last Name:HALLIBURTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:PERRY
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:5100 OBYRNES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95327
Mailing Address - Country:US
Mailing Address - Phone:209-984-5291
Mailing Address - Fax:
Practice Address - Street 1:5100 OBYRNES FERRY RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:CA
Practice Address - Zip Code:95327
Practice Address - Country:US
Practice Address - Phone:209-984-5291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20801103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical