Healthcare Provider Details

I. General information

NPI: 1831908813
Provider Name (Legal Business Name): GERALD RICHARDSON LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23909 W RENWICK RD STE 115
PLAINFIELD IL
60544-2109
US

IV. Provider business mailing address

23909 W RENWICK RD STE 115
PLAINFIELD IL
60544-2109
US

V. Phone/Fax

Practice location:
  • Phone: 815-714-8847
  • Fax:
Mailing address:
  • Phone: 815-714-8847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150114911
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: