Provider Demographics
NPI:1114568763
Name:RICHARDSON, SILAS
Entity Type:Individual
Prefix:
First Name:SILAS
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 E 2ND ST STE 224
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-6354
Mailing Address - Country:US
Mailing Address - Phone:507-474-4140
Mailing Address - Fax:507-474-4141
Practice Address - Street 1:902 E 2ND ST STE 224
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-6354
Practice Address - Country:US
Practice Address - Phone:507-474-4140
Practice Address - Fax:507-474-4141
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26330104100000X
MN303229101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker