Provider Demographics
NPI:1043767643
Name:RICHARDS, THERESA (CDP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CP60346077
Mailing Address - Street 1:235 SOUTH 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584
Mailing Address - Country:US
Mailing Address - Phone:360-426-0890
Mailing Address - Fax:
Practice Address - Street 1:235 S 3RD ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2255
Practice Address - Country:US
Practice Address - Phone:360-426-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60346077101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)