Provider Demographics
NPI:1982974648
Name:RICHMOND, TAEAN M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAEAN
Middle Name:M
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 WASHINGTON ST. SUITE B2
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:770-534-5141
Mailing Address - Fax:770-534-5141
Practice Address - Street 1:604 WASHINGTON ST. SUITE B2
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-534-5141
Practice Address - Fax:770-534-5141
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003032801AMedicaid