Healthcare Provider Details

I. General information

NPI: 1285916825
Provider Name (Legal Business Name): THERESA JEANETTE RICHARDSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA JEANETTE CYR

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 E 12 MILE RD SUITE 100
WARREN MI
48093-3400
US

IV. Provider business mailing address

11900 E 12 MILE RD SUITE 100
WARREN MI
48093-3400
US

V. Phone/Fax

Practice location:
  • Phone: 586-261-1960
  • Fax: 586-261-1961
Mailing address:
  • Phone: 586-261-1960
  • Fax: 586-261-1961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006158
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: