Provider Demographics
NPI:1376713156
Name:RICHBURG, DEIDRE MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:DEIDRE
Middle Name:MARIE
Last Name:RICHBURG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 CANTWELL LN
Mailing Address - Street 2:APT 12
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7632
Mailing Address - Country:US
Mailing Address - Phone:618-791-2387
Mailing Address - Fax:
Practice Address - Street 1:1449 CANTWELL LN
Practice Address - Street 2:APT 12
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-7632
Practice Address - Country:US
Practice Address - Phone:618-791-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008006348101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health