Provider Demographics
NPI:1770829954
Name:RICHARDSON, GENEVIEVE MARI
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:MARI
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 1:508 S PIN HIGH CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6049
Mailing Address - Country:US
Mailing Address - Phone:719-924-3796
Mailing Address - Fax:
Practice Address - Street 1:221 S UNION AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3490
Practice Address - Country:US
Practice Address - Phone:719-545-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO995885171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor