Provider Demographics
NPI:1073717906
Name:RICHARDSON, THERONE (LBSW)
Entity Type:Individual
Prefix:
First Name:THERONE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15833 VAUGHAN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4700 TIREMAN ST
Practice Address - Street 2:RM 111
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-4243
Practice Address - Country:US
Practice Address - Phone:313-897-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802080295104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker