Healthcare Provider Details

I. General information

NPI: 1245920834
Provider Name (Legal Business Name): RANDALL RICHARDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 DELMAR BLVD FL 3
SAINT LOUIS MO
63112-3054
US

IV. Provider business mailing address

5501 DELMAR BLVD FL 3
SAINT LOUIS MO
63112-3054
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-4908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: