Healthcare Provider Details

I. General information

NPI: 1811228174
Provider Name (Legal Business Name): DR. TERRI RICHMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S CALIFORNIA AVE
CHICAGO IL
60608-5107
US

IV. Provider business mailing address

2800 S CALIFORNIA AVE
CHICAGO IL
60608-5107
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042295A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number159-000526
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number07100013
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: