Provider Demographics
NPI:1740498930
Name:RICHARDSON, STACEY (DTA)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17736 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4870
Mailing Address - Country:US
Mailing Address - Phone:708-408-1320
Mailing Address - Fax:
Practice Address - Street 1:17736 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-4870
Practice Address - Country:US
Practice Address - Phone:708-408-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILSR39520701A222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILSR39520701AOtherDTA CREDENTIAL