Provider Demographics
NPI:1922328384
Name:RICHARDSON, DOUGLAS RAY (LADC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:RAY
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 N EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5742
Mailing Address - Country:US
Mailing Address - Phone:405-517-7679
Mailing Address - Fax:405-831-8506
Practice Address - Street 1:1340 N EASTERN AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5742
Practice Address - Country:US
Practice Address - Phone:405-517-7679
Practice Address - Fax:405-831-8506
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK714101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor