Healthcare Provider Details

I. General information

NPI: 1053520205
Provider Name (Legal Business Name): MRS. LORA DANIELLE RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 PHILLIPPE ROAD
WAYNESBURG KY
40489
US

IV. Provider business mailing address

462 PHILLIPPE RD
WAYNESBURG KY
40489
US

V. Phone/Fax

Practice location:
  • Phone: 606-379-1563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberKY-06-026A
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: