Provider Demographics
NPI:1629404272
Name:RICHARDS, THERESE LAVERN
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:LAVERN
Last Name:RICHARDS
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 1:1205 ECHO BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-1335
Mailing Address - Country:US
Mailing Address - Phone:702-771-1913
Mailing Address - Fax:
Practice Address - Street 1:7548 W SAHARA SUITE #101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117
Practice Address - Country:US
Practice Address - Phone:702-823-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-15
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid