Healthcare Provider Details

I. General information

NPI: 1790194496
Provider Name (Legal Business Name): ELIZABETH RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23800 W 10 MILE RD STE 210
SOUTHFIELD MI
48033-3141
US

IV. Provider business mailing address

PO BOX 1963
BELLEVILLE MI
48112-1963
US

V. Phone/Fax

Practice location:
  • Phone: 734-674-5751
  • Fax:
Mailing address:
  • Phone: 313-331-3435
  • Fax: 313-924-0605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097190
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: