Provider Demographics
NPI:1164049391
Name:RICHARDSON, LACOYA D (RBT, MA)
Entity Type:Individual
Prefix:
First Name:LACOYA
Middle Name:D
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RBT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 MILE STRETCH DR UNIT 3210
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34692-9709
Mailing Address - Country:US
Mailing Address - Phone:770-316-2633
Mailing Address - Fax:
Practice Address - Street 1:4653 DARLINGTON RD
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34690
Practice Address - Country:US
Practice Address - Phone:770-316-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-125695106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician