Provider Demographics
NPI:1154983583
Name:RICHARDSON, AVA
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4072 SAWYER ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-4953
Mailing Address - Country:US
Mailing Address - Phone:317-607-3812
Mailing Address - Fax:
Practice Address - Street 1:4072 SAWYER ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-4953
Practice Address - Country:US
Practice Address - Phone:317-607-3812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN46-1441860-Medicaid