Provider Demographics
NPI:1548976442
Name:RICHARDSON, ANTHONY (LPC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3142
Mailing Address - Country:US
Mailing Address - Phone:203-878-6365
Mailing Address - Fax:203-301-2397
Practice Address - Street 1:80 FERRY BLVD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-6079
Practice Address - Country:US
Practice Address - Phone:203-878-6365
Practice Address - Fax:203-301-2397
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005662101Y00000X
CT007553101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1851350300Medicaid