Provider Demographics
NPI:1578799433
Name:RICHARDSON, PAUL B (PTA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:B
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-1128
Mailing Address - Country:US
Mailing Address - Phone:260-927-8502
Mailing Address - Fax:
Practice Address - Street 1:818 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-1128
Practice Address - Country:US
Practice Address - Phone:260-927-8502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002497A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant