Provider Demographics
NPI:1164662425
Name:RICHARDSON, CLAUDETTE (PTA)
Entity Type:Individual
Prefix:
First Name:CLAUDETTE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 FAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3605
Mailing Address - Country:US
Mailing Address - Phone:608-346-8221
Mailing Address - Fax:
Practice Address - Street 1:7130 CRIMSON RIDGE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6222
Practice Address - Country:US
Practice Address - Phone:815-395-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160000621225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant