Provider Demographics
NPI:1245331347
Name:RICHARDSON, LAURA M (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:ZILLI-RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:317 GODWIN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1547
Mailing Address - Country:US
Mailing Address - Phone:201-241-2422
Mailing Address - Fax:201-241-2422
Practice Address - Street 1:317 GODWIN AVE STE 2
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1547
Practice Address - Country:US
Practice Address - Phone:201-241-2422
Practice Address - Fax:201-241-2422
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018389103TC0700X, 103TC0700X
NJ35SI00480300103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
191508Medicare PIN