Provider Demographics
NPI:1861005019
Name:RICHARDSON, MAXINE CASIE
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:CASIE
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:PO BOX 1864
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-5864
Mailing Address - Country:US
Mailing Address - Phone:304-887-0885
Mailing Address - Fax:
Practice Address - Street 1:202 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-2653
Practice Address - Country:US
Practice Address - Phone:304-887-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant