Provider Demographics
NPI:1326829227
Name:RICHARDSON, TALICIA (MS, LAC)
Entity Type:Individual
Prefix:
First Name:TALICIA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-2015
Mailing Address - Country:US
Mailing Address - Phone:214-912-0353
Mailing Address - Fax:
Practice Address - Street 1:5111 ROGERS AVE STE 561
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2047
Practice Address - Country:US
Practice Address - Phone:479-595-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2309022101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health