Provider Demographics
NPI:1598394272
Name:RICHARDSON, STEPHEN MARK (LICENSED COUNSELOR)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 THUNDER MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-2846
Mailing Address - Country:US
Mailing Address - Phone:417-416-8992
Mailing Address - Fax:
Practice Address - Street 1:1923 THUNDER MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2846
Practice Address - Country:US
Practice Address - Phone:417-416-8992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-05
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PENDING101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty