Provider Demographics
NPI:1760234611
Name:RICHARDSON, COREY D
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:D
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 OAKLEAF CV
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6243
Mailing Address - Country:US
Mailing Address - Phone:404-625-4832
Mailing Address - Fax:
Practice Address - Street 1:4360 OAKLEAF CV
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-6243
Practice Address - Country:US
Practice Address - Phone:404-625-4832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst