Provider Demographics
NPI:1003102906
Name:RICHARDSON, TOYA RENEE (CACI)
Entity Type:Individual
Prefix:
First Name:TOYA
Middle Name:RENEE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6439
Mailing Address - Country:US
Mailing Address - Phone:843-871-4790
Mailing Address - Fax:843-871-8579
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:SUIT 4
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6439
Practice Address - Country:US
Practice Address - Phone:843-871-4790
Practice Address - Fax:843-871-8579
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1005201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1851476337Medicaid