Healthcare Provider Details

I. General information

NPI: 1992028971
Provider Name (Legal Business Name): TREVOR RICHARDSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 STUDENT UNION
STILLWATER OK
74078
US

IV. Provider business mailing address

P.O. BOX 180 STUDENT UNION #1051
STILLWATER OK
74078
US

V. Phone/Fax

Practice location:
  • Phone: 405-269-6682
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1080
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1080
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: