Provider Demographics
NPI:1902895089
Name:BORN, RICHARD ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ROBERT
Last Name:BORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HUNTINGTON RD
Mailing Address - Street 2:#205
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7204
Mailing Address - Country:US
Mailing Address - Phone:706-543-7605
Mailing Address - Fax:706-543-2397
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:#205
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-543-7605
Practice Address - Fax:706-543-2397
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001283103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR93378Medicare UPIN
GA68BBGKDMedicare PIN