Basic Information
| Provider Information | |||||||||
| NPI: | 1225121510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHEY | ||||||||
| FirstName: | JACK | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 W.FAIRCHILD STREET | ||||||||
| Address2: | PSYCHIATRY/PSYCHOLOGY | ||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174317898 | ||||||||
| FaxNumber: | 2174317634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2006 | ||||||||
| LastUpdateDate: | 05/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149004431 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0533210001 | 01 | DMERC | OTHER |