Provider Demographics
NPI: | 1164514840 |
---|---|
Name: | RICHARDSON, JONATHAN HUGH THOMAS (PSYD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JONATHAN |
Middle Name: | HUGH THOMAS |
Last Name: | RICHARDSON |
Suffix: | |
Gender: | M |
Credentials: | PSYD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 6640 INTECH BLVD |
Mailing Address - Street 2: | STE 195 |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46278-2011 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-295-0608 |
Mailing Address - Fax: | 317-295-0622 |
Practice Address - Street 1: | 6640 INTECH BLVD |
Practice Address - Street 2: | STE 195 |
Practice Address - City: | INDIANAPOLIS |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46278-2011 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-295-0608 |
Practice Address - Fax: | 317-295-0622 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-29 |
Last Update Date: | 2008-08-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 99023416A | 103T00000X |
IN | 20042189 | 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 210870H | Medicare PIN |