Healthcare Provider Details

I. General information

NPI: 1629340914
Provider Name (Legal Business Name): DERYCK D. RICHARDSON, PH.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 E DUBLIN GRANVILLE RD SUITE 204
COLUMBUS OH
43229-3325
US

IV. Provider business mailing address

1425 E DUBLIN GRANVILLE RD SUITE 204
COLUMBUS OH
43229-3325
US

V. Phone/Fax

Practice location:
  • Phone: 614-888-5255
  • Fax: 614-888-2306
Mailing address:
  • Phone: 614-888-5255
  • Fax: 614-888-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2950
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2950
License Number StateOH

VIII. Authorized Official

Name: DR. DERYCK D'ARCY RICHARDSON
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 614-888-5255