Provider Demographics
NPI:1295364479
Name:RICHARDSON, VANESSA RENEE (MS, OTR)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:RENEE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9430
Mailing Address - Country:US
Mailing Address - Phone:317-332-9861
Mailing Address - Fax:317-893-4453
Practice Address - Street 1:21 S PARK BLVD STE 21
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8838
Practice Address - Country:US
Practice Address - Phone:317-449-2104
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007103A225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
433646OtherNBCOT