Provider Demographics
NPI:1659333516
Name:RICHARDSON, MICHELLE W (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:W
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-3256
Mailing Address - Country:US
Mailing Address - Phone:434-845-8765
Mailing Address - Fax:
Practice Address - Street 1:1912 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1708
Practice Address - Country:US
Practice Address - Phone:434-845-8765
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003497235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA216946OtherANTHEM PROVIDER NUMBERS
VA496612Medicare ID - Type Unspecified