Provider Demographics
NPI:1619676038
Name:RICHARDSON, JANELLE TRIVIA
Entity Type:Individual
Prefix:MISS
First Name:JANELLE
Middle Name:TRIVIA
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 1:680 THORNTON WAY
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2600
Mailing Address - Country:US
Mailing Address - Phone:470-734-8231
Mailing Address - Fax:
Practice Address - Street 1:680 THORNTON WAY
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2600
Practice Address - Country:US
Practice Address - Phone:470-734-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT23253882106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician