Provider Demographics
NPI:1487822169
Name:RICHARDSON, KENNETH CARNELL (BA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CARNELL
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-6662
Mailing Address - Country:US
Mailing Address - Phone:901-353-5440
Mailing Address - Fax:901-353-5464
Practice Address - Street 1:2150 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-6662
Practice Address - Country:US
Practice Address - Phone:901-353-5440
Practice Address - Fax:901-353-5464
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC834104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker