MEDICARE: RICHARD HIGINBOTHAM PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	SW8769	FL

General Provider Information

NPI Number	:	1467622472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD HIGINBOTHAM PA

Provider Business Mailing Address
First Line	:	3940 N FLAGLER DR
Second Line	:	#201
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-4441
Country	:	US
Telephone Number	:	734-320-6940
Fax Number	:

Provider Business Practice Location Address
First Line	:	614 NE JENSEN BEACH BLVD
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-4750
Country	:	US
Telephone Number	:	772-225-1226
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD HIGINBOTHAM PA
Credential	:	LCSW
Telephone Number	:	734-320-6940

Provider Enumeration Date	:	03/05/2008
Last Update Date	:	03/05/2008

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