Provider Demographics
NPI:1285962779
Name:RICHARDSON, COREY L (LCSW)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:L
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 REED ST
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-1334
Mailing Address - Country:US
Mailing Address - Phone:208-244-8771
Mailing Address - Fax:
Practice Address - Street 1:745 REED ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83211-1334
Practice Address - Country:US
Practice Address - Phone:208-244-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDIDAHO LCSW-289061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID28906OtherLCSW