MEDICARE: WILLIE RICHARDSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1942772181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIE RICHARDSON

Provider Business Mailing Address
First Line	:	3739 MAYFIELD RD APT 101
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1751
Country	:	US
Telephone Number	:	216-386-6415
Fax Number	:

Provider Business Practice Location Address
First Line	:	3739 MAYFIELD RD APT 101
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1751
Country	:	US
Telephone Number	:	216-386-6415
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2018
Last Update Date	:	12/28/2018

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