Healthcare Provider Details

I. General information

NPI: 1174808885
Provider Name (Legal Business Name): LAURA ELIZABETH RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11813 BLACKEYED SUSAN DR
RIVERVIEW FL
33579-1106
US

IV. Provider business mailing address

11813 BLACKEYED SUSAN DR
RIVERVIEW FL
33579-1106
US

V. Phone/Fax

Practice location:
  • Phone: 813-690-7444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 8547
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: