Provider Demographics
NPI:1558101048
Name:RICHMOND, KENNETH D
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:RICHMOND
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 1:1922 S TROY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2294
Mailing Address - Country:US
Mailing Address - Phone:646-276-4825
Mailing Address - Fax:
Practice Address - Street 1:1507 N MILWAUKEE AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2009
Practice Address - Country:US
Practice Address - Phone:773-386-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150111927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health