Provider Demographics
NPI:1962539387
Name:RICHARDSON, AVORY MCWILLIAMS (BS, MSCE)
Entity type:Individual
Prefix:MS
First Name:AVORY
Middle Name:MCWILLIAMS
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:BS, MSCE
Other - Prefix:
Other - First Name:AVORY
Other - Middle Name:MCWILLIAMS
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:5750A SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-3316
Mailing Address - Country:US
Mailing Address - Phone:251-662-7317
Mailing Address - Fax:251-662-7297
Practice Address - Street 1:5750A SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-3316
Practice Address - Country:US
Practice Address - Phone:251-662-7317
Practice Address - Fax:251-662-7297
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
AL4026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid