Provider Demographics
NPI:1649764713
Name:RICHARDSON, CLARISSA MARIE EDGE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLARISSA
Middle Name:MARIE EDGE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 LEACH RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62563-8061
Mailing Address - Country:US
Mailing Address - Phone:217-953-1343
Mailing Address - Fax:
Practice Address - Street 1:201 E MORGAN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2587
Practice Address - Country:US
Practice Address - Phone:217-953-1343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010899103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist