Healthcare Provider Details

I. General information

NPI: 1073178604
Provider Name (Legal Business Name): TEONNA MICHELLE RICHARDSON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4970 BELMONT AVE
YOUNGSTOWN OH
44505-1018
US

IV. Provider business mailing address

150 E MARKET ST
WARREN OH
44481-1141
US

V. Phone/Fax

Practice location:
  • Phone: 330-759-8237
  • Fax:
Mailing address:
  • Phone: 330-399-6451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS1000966
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1000966
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2406027
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: