Provider Demographics
NPI:1205510336
Name:RICHARDSON, OLIVER BUREN (LCADC, CSW)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:BUREN
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LCADC, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 LIMESTONE CT
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-4602
Mailing Address - Country:US
Mailing Address - Phone:502-337-2336
Mailing Address - Fax:
Practice Address - Street 1:2604 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1530
Practice Address - Country:US
Practice Address - Phone:502-436-3271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY289042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)