Provider Demographics
NPI:1477336923
Name:RICHARDSON, MICHAEL THEODORE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THEODORE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 17TH AVE S STE 5
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4781
Mailing Address - Country:US
Mailing Address - Phone:208-901-9274
Mailing Address - Fax:
Practice Address - Street 1:824 17TH AVE S STE 5
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4781
Practice Address - Country:US
Practice Address - Phone:208-901-9274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist