Provider Demographics
NPI:1588875959
Name:RICHARDSON, CARLA BOELTE (VATL, ATC)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:BOELTE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:VATL, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 GARRISONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-3702
Mailing Address - Country:US
Mailing Address - Phone:540-659-6408
Mailing Address - Fax:
Practice Address - Street 1:572 GARRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-3702
Practice Address - Country:US
Practice Address - Phone:540-659-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260010462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer