Provider Demographics
NPI:1912497124
Name:RICHARDSON, RENEE MARIA
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIA
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 1:168 ANTIOCH RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE HOCKING
Mailing Address - State:OH
Mailing Address - Zip Code:45742-5059
Mailing Address - Country:US
Mailing Address - Phone:740-989-0257
Mailing Address - Fax:
Practice Address - Street 1:168 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:LITTLE HOCKING
Practice Address - State:OH
Practice Address - Zip Code:45742-5059
Practice Address - Country:US
Practice Address - Phone:740-989-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.164135101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)