1285647305 NPI number — RICHARD B KIRK MSW LCSW

Table of content: RICHARD B KIRK MSW LCSW (NPI 1285647305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285647305 NPI number — RICHARD B KIRK MSW LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRK
Provider First Name:
RICHARD
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIRK
Provider Other First Name:
RICHARD
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1285647305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9054
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37615-9054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-467-3600
Provider Business Mailing Address Fax Number:
423-467-3696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1570 WAVERLY RD
Provider Second Line Business Practice Location Address:
HOLSTON COUNSELING SERVICES
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-1300
Provider Business Practice Location Address Fax Number:
423-224-1375
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LCSW617 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW617 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 089854 . This is a "ANTHEM PREF TRIGON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0096965 . This is a "MAGELLAN NAVIGATOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 13052 . This is a "UBH HEALTHPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 334969 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3920015 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 089854 . This is a "ANTHEM PROF TRIGON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0096965 . This is a "MAGELLAN PINNACLE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0096965 . This is a "MAGELLAN SUMMIT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3920247 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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