Provider Demographics
NPI:1386653244
Name:RICHARDSON, MARK A (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 ALBANY ST
Mailing Address - Street 2:DOWLING 7 NORTH
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2525
Mailing Address - Country:US
Mailing Address - Phone:617-414-1922
Mailing Address - Fax:617-638-8542
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:DOWLING 9
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-1922
Practice Address - Fax:617-414-5546
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA7431103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0526584Medicaid
W50350Medicare ID - Type Unspecified