Provider Demographics
NPI:1134693534
Name:RICHARDSON, MARTAVIA
Entity Type:Individual
Prefix:
First Name:MARTAVIA
Middle Name:
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 1:25 SAMUEL MORSE WAY APT 862
Mailing Address - Street 2:862
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129
Mailing Address - Country:US
Mailing Address - Phone:857-207-9682
Mailing Address - Fax:
Practice Address - Street 1:25 SAMUEL MORSE WAY APT 862
Practice Address - Street 2:862
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129
Practice Address - Country:US
Practice Address - Phone:857-207-9682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty