Provider Demographics
NPI:1801990171
Name:RICHARDSON, MICHELLE LEA (OTR)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEA
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 HARLOW HILL RD
Mailing Address - Street 2:
Mailing Address - City:TURNER
Mailing Address - State:ME
Mailing Address - Zip Code:04282-3521
Mailing Address - Country:US
Mailing Address - Phone:207-225-2857
Mailing Address - Fax:
Practice Address - Street 1:1318 US ROUTE 202
Practice Address - Street 2:SUITE D
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-3821
Practice Address - Country:US
Practice Address - Phone:207-377-5902
Practice Address - Fax:207-377-5904
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME015505OtherANTHEM