Provider Demographics
NPI:1154603082
Name:RICHARDSON, GARRICK JOHN
Entity type:Individual
Prefix:MR
First Name:GARRICK
Middle Name:JOHN
Last Name:RICHARDSON
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 1:1637 WHITEASH AVE.
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619
Mailing Address - Country:US
Mailing Address - Phone:559-430-6805
Mailing Address - Fax:
Practice Address - Street 1:5446 N PALM AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-1945
Practice Address - Country:US
Practice Address - Phone:559-430-6805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA683611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical