Provider Demographics
NPI:1891844882
Name:RICHARDSON, RISA THOMPSON (PHD)
Entity Type:Individual
Prefix:
First Name:RISA
Middle Name:THOMPSON
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:RISA
Other - Middle Name:NAKASE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:13000 BRUCE B DOWNS BLVD
Mailing Address - Street 2:MH&BS 116B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4745
Mailing Address - Country:US
Mailing Address - Phone:813-972-2000
Mailing Address - Fax:813-903-4814
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:MH&BS 116B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:813-903-4814
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS40-010103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124390Medicaid
MS680000222Medicare ID - Type UnspecifiedPROVIDER NUMBER
MS00124390Medicaid