Provider Demographics
NPI:1467070854
Name:RICHARDSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHERAYE
Other - Middle Name:NICOLE
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24654 N LAKE PLEASANT PKWY STE 103-814
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-1359
Mailing Address - Country:US
Mailing Address - Phone:480-648-9699
Mailing Address - Fax:
Practice Address - Street 1:24654 N LAKE PLEASANT PKWY STE 103-814
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-1359
Practice Address - Country:US
Practice Address - Phone:480-648-9699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
AZ101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional