Provider Demographics
NPI:1255985537
Name:RICHARDSON, DAVID MICHAEL (CERTIFIED PEER COUNS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:CERTIFIED PEER COUNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1433
Mailing Address - Country:US
Mailing Address - Phone:360-357-2582
Mailing Address - Fax:360-357-2821
Practice Address - Street 1:1000 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1433
Practice Address - Country:US
Practice Address - Phone:360-357-2582
Practice Address - Fax:360-357-2821
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2146438Medicaid