Healthcare Provider Details

I. General information

NPI: 1750047312
Provider Name (Legal Business Name): RICHARD SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3562 E US HIGHWAY 30
WARSAW IN
46580-6720
US

IV. Provider business mailing address

16965 HAMPTON DR
GRANGER IN
46530-9177
US

V. Phone/Fax

Practice location:
  • Phone: 574-372-4489
  • Fax:
Mailing address:
  • Phone: 224-908-8128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99128465A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401223648
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: