Provider Demographics
NPI:1700667375
Name:RICHARDSON, BIANCA
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 KOHLERS XING STE 450
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-2464
Mailing Address - Country:US
Mailing Address - Phone:737-615-8436
Mailing Address - Fax:
Practice Address - Street 1:115 KOHLERS XING STE 450
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-2464
Practice Address - Country:US
Practice Address - Phone:737-615-8436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1912409221700000X, 174400000X
TX1912409405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No405300000XOther Service ProvidersPrevention Professional