Provider Demographics
NPI:1396148995
Name:RICHARDSON, PORTIA (LAC)
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:PORTIA
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:1224 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1130
Mailing Address - Country:US
Mailing Address - Phone:612-298-8738
Mailing Address - Fax:
Practice Address - Street 1:1224 2ND ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1130
Practice Address - Country:US
Practice Address - Phone:612-298-8738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-27
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1707171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist