Provider Demographics
NPI:1457019986
Name:RICHARDSON, NATHAN A (PTA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W WALL ST
Mailing Address - Street 2:
Mailing Address - City:MULBERRY GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:62262-1017
Mailing Address - Country:US
Mailing Address - Phone:618-339-3823
Mailing Address - Fax:
Practice Address - Street 1:400 S STATION RD
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2743
Practice Address - Country:US
Practice Address - Phone:618-288-5014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008987225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant