Provider Demographics
NPI:1750614525
Name:RICHARDSON, GARY (LCDC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 N FM 179
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416
Mailing Address - Country:US
Mailing Address - Phone:806-797-8003
Mailing Address - Fax:806-797-7916
Practice Address - Street 1:1705 N FM 179
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-9441
Practice Address - Country:US
Practice Address - Phone:806-797-8003
Practice Address - Fax:806-797-7916
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9073101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065363601Medicaid