Provider Demographics
NPI:1164448643
Name:RICHARDSON, MARC JEROME
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:JEROME
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 1:10 CACTUS ST
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:SC
Mailing Address - Zip Code:29510-3187
Mailing Address - Country:US
Mailing Address - Phone:843-264-9110
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8903
Practice Address - Country:US
Practice Address - Phone:843-347-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor