Provider Demographics
NPI:1093882151
Name:RICHARDSON, SHIRLEY A
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:A
Last Name:RICHARDSON
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 1:6034 CHESTER AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2266
Mailing Address - Country:US
Mailing Address - Phone:904-564-0518
Mailing Address - Fax:904-370-3267
Practice Address - Street 1:6034 CHESTER AVE STE 204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2266
Practice Address - Country:US
Practice Address - Phone:904-564-0518
Practice Address - Fax:904-370-3267
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH 9783101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health