Provider Demographics
NPI:1821129669
Name:RICHARDSON, ROBERTO FERNANDO (MA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:FERNANDO
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 LINCOLN WAY E
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-3220
Mailing Address - Country:US
Mailing Address - Phone:574-232-2255
Mailing Address - Fax:574-232-8968
Practice Address - Street 1:500 N NAPPANEE ST STE 4A
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1502
Practice Address - Country:US
Practice Address - Phone:574-522-8992
Practice Address - Fax:574-232-8968
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor