Healthcare Provider Details

I. General information

NPI: 1972558716
Provider Name (Legal Business Name): KEITH RICHTER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 WESTBROOK RD
ESSEX CT
06426-1517
US

IV. Provider business mailing address

222 MAIN STREET EXT PO BOX 1000
MIDDLETOWN CT
06457-4406
US

V. Phone/Fax

Practice location:
  • Phone: 860-767-2025
  • Fax: 860-767-1053
Mailing address:
  • Phone: 860-343-5300
  • Fax: 860-343-5307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005287
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: