Provider Demographics
NPI:1427044296
Name:RICHARDSON, ILENE ANN (LCPC)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:ANN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15262 RUSSELL DR
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417-3004
Mailing Address - Country:US
Mailing Address - Phone:410-713-0709
Mailing Address - Fax:410-546-0264
Practice Address - Street 1:15262 RUSSELL DR
Practice Address - Street 2:
Practice Address - City:ONANCOCK
Practice Address - State:VA
Practice Address - Zip Code:23417-3004
Practice Address - Country:US
Practice Address - Phone:410-713-0709
Practice Address - Fax:410-546-0264
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412815000OtherSTATE OF MARYLAND
MD805688000OtherMAGELLAN
MD7452697OtherAETNA