Provider Demographics
NPI:1356590673
Name:RICHARDSON, TONI SIMONE (MBA, MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TONI
Middle Name:SIMONE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MBA, MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 BOULDERCREST RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3605
Mailing Address - Country:US
Mailing Address - Phone:678-334-8508
Mailing Address - Fax:
Practice Address - Street 1:4606 BOULDERCREST RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3605
Practice Address - Country:US
Practice Address - Phone:678-334-8508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006848235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist