Provider Demographics
NPI:1104531599
Name:WADSWORTH, RICHARD BRENT JR (LAPC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:BRENT
Last Name:WADSWORTH
Suffix:JR
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 DARTMOTH WAY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5860
Mailing Address - Country:US
Mailing Address - Phone:404-829-9722
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR STE 201
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3256
Practice Address - Country:US
Practice Address - Phone:770-812-3839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA17844Medicaid