Provider Demographics
NPI:1083106090
Name:RICHARD, THERESA LYNN
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:RICHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 ELOCHOMAN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CATHLAMET
Mailing Address - State:WA
Mailing Address - Zip Code:98612-9602
Mailing Address - Country:US
Mailing Address - Phone:350-795-8630
Mailing Address - Fax:
Practice Address - Street 1:42 ELOCHOMAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9602
Practice Address - Country:US
Practice Address - Phone:350-795-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60862263OtherWA DOH