Provider Demographics
NPI:1124493176
Name:RICHARD, MARTIN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:RICHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 COOLIDGE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2622
Mailing Address - Country:US
Mailing Address - Phone:337-266-7170
Mailing Address - Fax:337-266-7998
Practice Address - Street 1:1144 COOLIDGE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2622
Practice Address - Country:US
Practice Address - Phone:337-266-7170
Practice Address - Fax:337-266-7998
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health