Provider Demographics
NPI:1104536382
Name:KIM RICHARDSON THERAPY LLC
Entity type:Organization
Organization Name:KIM RICHARDSON THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LMSW, LPC
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ADRIENNE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-882-5067
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:SAUGATUCK
Mailing Address - State:MI
Mailing Address - Zip Code:49453-0444
Mailing Address - Country:US
Mailing Address - Phone:312-882-5067
Mailing Address - Fax:
Practice Address - Street 1:186 S RIVER AVE STE 7
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2848
Practice Address - Country:US
Practice Address - Phone:312-882-5067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-29
Last Update Date:2023-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1326305806Medicaid