Healthcare Provider Details

I. General information

NPI: 1427044296
Provider Name (Legal Business Name): ILENE ANN RICHARDSON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 01/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15262 RUSSELL DR
ONANCOCK VA
23417-3004
US

IV. Provider business mailing address

15262 RUSSELL DR
ONANCOCK VA
23417-3004
US

V. Phone/Fax

Practice location:
  • Phone: 410-713-0709
  • Fax: 410-546-0264
Mailing address:
  • Phone: 410-713-0709
  • Fax: 410-546-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC1278
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: