=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164067146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH RICHARDSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2019
-----------------------------------------------------
Last Update Date | 11/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4207 SAN JUAN DR
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-5375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-855-4293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5204 MORRIS AVE APT 203
-----------------------------------------------------
City | SUITLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20746-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-855-4293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0019016159
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------