Provider Demographics
NPI:1003904947
Name:RICHARDSON, IVANNA M (EDD LMFT LPC)
Entity Type:Individual
Prefix:DR
First Name:IVANNA
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:EDD LMFT LPC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12970 W BLUEMOUND RD
Mailing Address - Street 2:#105
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122
Mailing Address - Country:US
Mailing Address - Phone:262-787-2907
Mailing Address - Fax:
Practice Address - Street 1:12970 W BLUEMOUND RD
Practice Address - Street 2:#105
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122
Practice Address - Country:US
Practice Address - Phone:262-787-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1685125101Y00000X
WI493124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist