Provider Demographics
NPI:1891531315
Name:RICHARDSON, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 MONT HALL RD
Mailing Address - Street 2:
Mailing Address - City:HALLSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75650-4424
Mailing Address - Country:US
Mailing Address - Phone:903-452-3454
Mailing Address - Fax:
Practice Address - Street 1:1916 MONT HALL RD
Practice Address - Street 2:
Practice Address - City:HALLSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75650-4424
Practice Address - Country:US
Practice Address - Phone:903-452-3454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QM0801X
TX18292261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)