Provider Demographics
NPI:1487865655
Name:RICHARDSON, MICHAEL CHARLES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-1785
Mailing Address - Country:US
Mailing Address - Phone:908-630-0777
Mailing Address - Fax:908-832-5861
Practice Address - Street 1:12 RIDGE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-1785
Practice Address - Country:US
Practice Address - Phone:908-630-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00362800103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ043214Medicare ID - Type UnspecifiedPROVIDER NUMBER