Provider Demographics
NPI:1316909740
Name:RICHARDSON, BRIAN JON (PSYD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JON
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 N ARLINGTON HEIGHTS RD
Mailing Address - Street 2:SUITE 301B
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-1557
Mailing Address - Country:US
Mailing Address - Phone:847-222-0793
Mailing Address - Fax:847-222-9769
Practice Address - Street 1:3233 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:SUITE 301B
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1557
Practice Address - Country:US
Practice Address - Phone:847-222-0793
Practice Address - Fax:847-222-9769
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004102103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213503OtherMEDICARE ID
ILK27255Medicare UPIN