Provider Demographics
NPI:1417717513
Name:RICHARDSON, FRITZ JR (CEO, OWNER)
Entity Type:Individual
Prefix:
First Name:FRITZ
Middle Name:
Last Name:RICHARDSON
Suffix:JR
Gender:M
Credentials:CEO, OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NW 62ND ST STE B100
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1718
Mailing Address - Country:US
Mailing Address - Phone:754-900-0503
Mailing Address - Fax:754-289-4250
Practice Address - Street 1:2700 NW 62ND ST STE B100
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1718
Practice Address - Country:US
Practice Address - Phone:754-900-0503
Practice Address - Fax:754-289-4250
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14064251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health