MEDICARE: DWIGHT M. RICHARD

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LICDC.965713	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	965713	OH
3	101YM0800X	Mental Health Counselor	E.0003239	OH
4	101YP2500X	Professional Counselor	E.0003239	OH
5	104100000X	Social Worker	S.0021026	OH
6	101YP2500X	Professional Counselor	E.0003239-SUPV	OH

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1770985152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWIGHT M. RICHARD

Provider Business Mailing Address
First Line	:	6460 HARRISON AVE STE 200
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45247-7958
Country	:	US
Telephone Number	:	513-941-4999
Fax Number	:	513-694-0168

Provider Business Practice Location Address
First Line	:	1421 PARKER CT
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45504-2855
Country	:	US
Telephone Number	:	513-941-4999
Fax Number	:	513-694-0168

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

Provider Enumeration Date	:	09/17/2014
Last Update Date	:	05/10/2023

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039