Provider Demographics
NPI:1972838266
Name:RICHARDSON, CHRIS DWIGHT (PTA)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:DWIGHT
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#6 CTY RD. 5149
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413
Mailing Address - Country:US
Mailing Address - Phone:505-215-6613
Mailing Address - Fax:
Practice Address - Street 1:#6 CTY RD 5149
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413
Practice Address - Country:US
Practice Address - Phone:505-215-6614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0554225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant