Provider Demographics
NPI:1639394448
Name:RICHARDSON, TARA G
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:G
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 1:8951 POSEY DR
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9479
Mailing Address - Country:US
Mailing Address - Phone:734-651-2348
Mailing Address - Fax:
Practice Address - Street 1:29865 6 MILE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3673
Practice Address - Country:US
Practice Address - Phone:734-522-0280
Practice Address - Fax:734-522-3654
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010780681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
M56380038Medicare ID - Type Unspecified