Provider Demographics
NPI:1376947002
Name:RICHARDSON, ANGIE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 W KING ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7157
Mailing Address - Country:US
Mailing Address - Phone:208-323-1868
Mailing Address - Fax:
Practice Address - Street 1:7950 W KING ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7157
Practice Address - Country:US
Practice Address - Phone:208-323-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5349101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional