Healthcare Provider Details

I. General information

NPI: 1437403326
Provider Name (Legal Business Name): SAMUEL RICHARDSON III DCC, LCPC, CTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 CHESTNUT ST
CHERAW SC
29520-3414
US

IV. Provider business mailing address

9 CHURCH ST
CHERAW SC
29520-2707
US

V. Phone/Fax

Practice location:
  • Phone: 843-337-1979
  • Fax: 843-537-1479
Mailing address:
  • Phone: 843-337-1979
  • Fax: 843-537-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15461
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15461
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number15461
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number15461
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number15461
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number15461
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: