Healthcare Provider Details

I. General information

NPI: 1033800107
Provider Name (Legal Business Name): KYLE LARS RICHARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BIG TREES RD STE D
MURPHYS CA
95247-9101
US

IV. Provider business mailing address

4250 FOWLER LN STE 204
DIAMOND SPRINGS CA
95619-9782
US

V. Phone/Fax

Practice location:
  • Phone: 209-890-7124
  • Fax:
Mailing address:
  • Phone: 530-295-1491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: