Provider Demographics
NPI:1629051776
Name:RICHARDSON, RORY FLEMING (PHD, FICPPM)
Entity Type:Individual
Prefix:DR
First Name:RORY
Middle Name:FLEMING
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PHD, FICPPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 109
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-0109
Mailing Address - Country:US
Mailing Address - Phone:541-994-4462
Mailing Address - Fax:541-994-6329
Practice Address - Street 1:4466 NE DEVILS LAKE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-5197
Practice Address - Country:US
Practice Address - Phone:541-994-4462
Practice Address - Fax:541-994-6329
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0068101YM0800X
OR1249103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR092951Medicaid
ORR 7WBQ0OtherPACC HMO
OR00543OtherMEDICARE NORIDIAN EDI
OR069078000OtherREGENCE BLUE CROSS BLUE S
OR171641OtherMENTAL HEALTH NETWORK
OR150576Medicaid
OR090021822OtherSTATE OF OREGON DDS
ORR100980Medicare PIN
OR069078000OtherREGENCE BLUE CROSS BLUE S