MEDICARE: DR. RICHARD RALEIGH RAUBOLT PH.D.

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	103T00000X	Psychologist	6301003233	MI

General Provider Information

NPI Number	:	1568608230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD RALEIGH RAUBOLT PH.D.

Provider Business Mailing Address
First Line	:	2735 WOODCLIFF CIR SE
Second Line	:
City	:	EAST GRAND RAPIDS
State	:	MI
Zip	:	49506-3152
Country	:	US
Telephone Number	:	616-957-0647
Fax Number	:	616-957-9619

Provider Business Practice Location Address
First Line	:	967 SPAULDING AVE SE
Second Line	:	SUITE D
City	:	ADA
State	:	MI
Zip	:	49301-3700
Country	:	US
Telephone Number	:	616-940-1100
Fax Number	:	616-957-9619

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2008
Last Update Date	:	12/30/2008

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