Provider Demographics
NPI:1073052445
Name:RICHARDSON, DUSTIN (LCPC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 CHILDRESS TER
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2038
Mailing Address - Country:US
Mailing Address - Phone:410-938-0636
Mailing Address - Fax:410-766-0240
Practice Address - Street 1:1406 CRAIN HWY S STE 104
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4086
Practice Address - Country:US
Practice Address - Phone:410-766-6624
Practice Address - Fax:410-766-0240
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-18
Last Update Date:2017-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7682101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional