Provider Demographics
NPI:1952009870
Name:RICHARDSON, SHAY (LMBT)
Entity Type:Individual
Prefix:MISS
First Name:SHAY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 KELLS LN APT 201
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-4190
Mailing Address - Country:US
Mailing Address - Phone:336-409-3697
Mailing Address - Fax:
Practice Address - Street 1:2105 W CORNWALLIS DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7037
Practice Address - Country:US
Practice Address - Phone:336-235-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20432225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist