Basic Information
| Provider Information | |||||||||
| NPI: | 1770985152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARD | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC-SC, LSW, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11923 S WOLF CREEK PIKE | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453099340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377761052 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 680 NORTHLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452403248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139414999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 965713 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | E.0003239 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | E.0003239 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.