Provider Demographics
NPI:1538781679
Name:RICHIE, DAVID R (PH,D)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:RICHIE
Suffix:
Gender:M
Credentials:PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-3573
Mailing Address - Country:US
Mailing Address - Phone:731-658-7150
Mailing Address - Fax:
Practice Address - Street 1:680 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-3573
Practice Address - Country:US
Practice Address - Phone:731-658-7150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001233103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty