Provider Demographics
NPI:1164719084
Name:RICHARDSON, SAMUEL LEE (MS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LEE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 N BUFFALO DR STE 207
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-7411
Mailing Address - Country:US
Mailing Address - Phone:702-600-6335
Mailing Address - Fax:
Practice Address - Street 1:3320 N BUFFALO DR STE 207
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7411
Practice Address - Country:US
Practice Address - Phone:702-659-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0082106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist