Provider Demographics
NPI:1235363524
Name:RICHARDSON, KEVIN (RN)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 W EL SEGUNDO BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-3315
Mailing Address - Country:US
Mailing Address - Phone:323-241-6730
Mailing Address - Fax:323-756-1163
Practice Address - Street 1:2311 W EL SEGUNDO BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-3315
Practice Address - Country:US
Practice Address - Phone:323-241-6730
Practice Address - Fax:323-756-1163
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA663729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA663729OtherCALIFORNIA BOARD OF REGISTERED NURSES