Provider Demographics
NPI:1295299907
Name:RICHARDSON, SABRINA (MSW, CBHCMS)
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MSW, CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 EVANS AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9302
Mailing Address - Country:US
Mailing Address - Phone:239-275-3222
Mailing Address - Fax:
Practice Address - Street 1:2789 ORTIZ AVENUE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7806
Practice Address - Country:US
Practice Address - Phone:239-275-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-27
Last Update Date:2019-06-24
Deactivation Date:2019-05-19
Deactivation Code:
Reactivation Date:2019-05-29
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 104100000X
FLCBHCMS100575171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator