Healthcare Provider Details

I. General information

NPI: 1750614525
Provider Name (Legal Business Name): GARY RICHARDSON LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 N FM 179
LUBBOCK TX
79416-9441
US

IV. Provider business mailing address

1705 N FM 179
LUBBOCK TX
79416
US

V. Phone/Fax

Practice location:
  • Phone: 806-797-8003
  • Fax: 806-797-7916
Mailing address:
  • Phone: 806-797-8003
  • Fax: 806-797-7916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9073
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: