Provider Demographics
NPI:1568925782
Name:RICHARDSON, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 EXCELSIOR SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL FORK
Mailing Address - State:VA
Mailing Address - Zip Code:24352-4015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:836 GLENDALE RD
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2490
Practice Address - Country:US
Practice Address - Phone:276-236-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601520208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation