Healthcare Provider Details

I. General information

NPI: 1417250093
Provider Name (Legal Business Name): KEITH RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E MAIN ST STE A
SALISBURY MD
21801-5044
US

IV. Provider business mailing address

220 E MAIN ST STE A
SALISBURY MD
21801-5044
US

V. Phone/Fax

Practice location:
  • Phone: 410-860-9600
  • Fax:
Mailing address:
  • Phone: 410-860-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC0544
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-2739
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: