Provider Demographics
NPI:1043773575
Name:WARDLAW, RICHARD (NCSP (PENDING))
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WARDLAW
Suffix:
Gender:M
Credentials:NCSP (PENDING)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 OLD MINDEN RD STE 500
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-2305
Mailing Address - Country:US
Mailing Address - Phone:318-584-7166
Mailing Address - Fax:
Practice Address - Street 1:2323 OLD MINDEN RD STE 500
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2305
Practice Address - Country:US
Practice Address - Phone:318-584-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator