Provider Demographics
NPI:1902316243
Name:WEBSTER, RICHARD III
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WEBSTER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 S HUTCHINS ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3416
Mailing Address - Country:US
Mailing Address - Phone:209-331-6784
Mailing Address - Fax:
Practice Address - Street 1:1103 N B ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0326
Practice Address - Country:US
Practice Address - Phone:916-378-8266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-30
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA1108171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)