Provider Demographics
NPI:1861558678
Name:DIWALD, RICHARD ALLAN (RAS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLAN
Last Name:DIWALD
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10719B RANCHERIA RD
Mailing Address - Street 2:
Mailing Address - City:UPPER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95485-9572
Mailing Address - Country:US
Mailing Address - Phone:707-245-4624
Mailing Address - Fax:707-275-8005
Practice Address - Street 1:991 PARALLEL DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5720
Practice Address - Country:US
Practice Address - Phone:707-263-8162
Practice Address - Fax:707-263-9336
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD0412282000101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)