Healthcare Provider Details

I. General information

NPI: 1821129669
Provider Name (Legal Business Name): ROBERTO FERNANDO RICHARDSON MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N NAPPANEE ST STE 4A
ELKHART IN
46514-1502
US

IV. Provider business mailing address

611 LINCOLN WAY E
SOUTH BEND IN
46601-3220
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-8992
  • Fax: 574-232-8968
Mailing address:
  • Phone: 574-232-2255
  • Fax: 574-232-8968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: