Provider Demographics
NPI:1336408228
Name:RICHARDSON, MICHAEL SCOTT (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 OLD LYNN GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-8112
Mailing Address - Country:US
Mailing Address - Phone:270-293-5687
Mailing Address - Fax:270-759-5127
Practice Address - Street 1:1124 OLD LYNN GROVE RD
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-8112
Practice Address - Country:US
Practice Address - Phone:270-293-5687
Practice Address - Fax:270-759-5127
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR0056225X00000X
TNOT103225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist