Provider Demographics
NPI:1154510196
Name:RICHARDSON, MICHAEL DAVID (EDD, LCPC, CRADC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:EDD, LCPC, CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12496 OLD 79
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:MO
Mailing Address - Zip Code:63459-2741
Mailing Address - Country:US
Mailing Address - Phone:573-248-2051
Mailing Address - Fax:573-248-2051
Practice Address - Street 1:12496 OLD 79
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:MO
Practice Address - Zip Code:63459-2741
Practice Address - Country:US
Practice Address - Phone:573-248-2051
Practice Address - Fax:573-248-2051
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001395101YP2500X
IL180.002197101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498873918Medicaid