Provider Demographics
NPI:1831426568
Name:RICHARDSON, REGINALD ANTHONY
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:ANTHONY
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10020 NW 142ND ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-1334
Mailing Address - Country:US
Mailing Address - Phone:405-802-9884
Mailing Address - Fax:
Practice Address - Street 1:10020 NW 142ND ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-1334
Practice Address - Country:US
Practice Address - Phone:405-802-9884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-23-315680106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty