Provider Demographics
NPI:1013330125
Name:RICHARDSON, DEBRA JANE (MED)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JANE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:WETUMKA
Mailing Address - State:OK
Mailing Address - Zip Code:74883-4523
Mailing Address - Country:US
Mailing Address - Phone:214-499-8814
Mailing Address - Fax:
Practice Address - Street 1:208 E SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:WETUMKA
Practice Address - State:OK
Practice Address - Zip Code:74883-4523
Practice Address - Country:US
Practice Address - Phone:214-499-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK11646592499Medicaid