Provider Demographics
NPI:1134900855
Name:RICHARDSON, LANISE
Entity type:Individual
Prefix:
First Name:LANISE
Middle Name:
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 1:14992 NC HIGHWAY 39
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-7496
Mailing Address - Country:US
Mailing Address - Phone:919-427-9746
Mailing Address - Fax:
Practice Address - Street 1:14992 NC HIGHWAY 39
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-7496
Practice Address - Country:US
Practice Address - Phone:919-427-9746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician