Healthcare Provider Details

I. General information

NPI: 1114853082
Provider Name (Legal Business Name): KATHERINE CAROL RICHERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 BRASELTON HWY STE 103
DACULA GA
30019-5907
US

IV. Provider business mailing address

3615 BRASELTON HWY STE 103
DACULA GA
30019-5907
US

V. Phone/Fax

Practice location:
  • Phone: 678-377-9634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number043677399
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: