Healthcare Provider Details

I. General information

NPI: 1740039007
Provider Name (Legal Business Name): LISA RICHARDSON LCPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W VICKERY BLVD
FORT WORTH TX
76104-1025
US

IV. Provider business mailing address

1101 W VICKERY BLVD
FORT WORTH TX
76104-1025
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-6295
  • Fax:
Mailing address:
  • Phone: 682-885-6295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number2255
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number2255
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: