Provider Demographics
NPI:1932617347
Name:RICHARDSON, KAYLAN RANDALL
Entity Type:Individual
Prefix:
First Name:KAYLAN
Middle Name:RANDALL
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 1:46336 CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-4027
Mailing Address - Country:US
Mailing Address - Phone:985-507-4167
Mailing Address - Fax:
Practice Address - Street 1:1126 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5972
Practice Address - Country:US
Practice Address - Phone:985-956-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health