Provider Demographics
NPI:1407455959
Name:RICHARDSON, MARY LEE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
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 1:1591 GLENN PL SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1170
Mailing Address - Country:US
Mailing Address - Phone:216-702-7316
Mailing Address - Fax:
Practice Address - Street 1:1591 GLENN PL SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-1170
Practice Address - Country:US
Practice Address - Phone:216-702-7316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer