Provider Demographics
NPI:1629340914
Name:DERYCK D. RICHARDSON, PH.D. LLC
Entity Type:Organization
Organization Name:DERYCK D. RICHARDSON, PH.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERYCK
Authorized Official - Middle Name:D'ARCY
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:614-888-5255
Mailing Address - Street 1:1425 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-3325
Mailing Address - Country:US
Mailing Address - Phone:614-888-5255
Mailing Address - Fax:614-888-2306
Practice Address - Street 1:1425 E DUBLIN GRANVILLE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-3325
Practice Address - Country:US
Practice Address - Phone:614-888-5255
Practice Address - Fax:614-888-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2950261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0453389Medicaid
OHRICP12632Medicare PIN
OH0453389Medicaid