Provider Demographics
NPI:1003232174
Name:RICHARDSON, DAVIDA
Entity Type:Individual
Prefix:
First Name:DAVIDA
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:PO BOX 90515
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30364-0515
Mailing Address - Country:US
Mailing Address - Phone:678-612-8493
Mailing Address - Fax:
Practice Address - Street 1:6812 MADDOX RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-3223
Practice Address - Country:US
Practice Address - Phone:678-612-8493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008207235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist