Provider Demographics
NPI:1083133003
Name:RICHARDSON, CARLOS DE'WAYNE (LPC)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:DE'WAYNE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CENTURY PARK S STE 102
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35226-3922
Mailing Address - Country:US
Mailing Address - Phone:205-565-6554
Mailing Address - Fax:888-386-9624
Practice Address - Street 1:100 CENTURY PARK S STE 102
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35226-3922
Practice Address - Country:US
Practice Address - Phone:205-565-6554
Practice Address - Fax:888-386-9624
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2131A101YM0800X
AL3843101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL46--1731139Medicaid
AL46-1731139OtherOTHER