Provider Demographics
NPI:1912075383
Name:HANCOCK RICHARDSON, LORI D (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:D
Last Name:HANCOCK RICHARDSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:D
Other - Last Name:HANCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:820 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7104
Mailing Address - Country:US
Mailing Address - Phone:505-356-9133
Mailing Address - Fax:
Practice Address - Street 1:501 S ABILENE AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6380
Practice Address - Country:US
Practice Address - Phone:505-359-3707
Practice Address - Fax:505-356-6682
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3385235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67824854Medicaid