=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598049512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN FREDERICK RICHARDSON II MS,CCC-SLP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2011
-----------------------------------------------------
Last Update Date | 10/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5908 LYONS VIEW PIKE
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37919-7520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-588-0508
-----------------------------------------------------
Fax | 865-558-0226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2035 HAPPY CREEK RD
-----------------------------------------------------
City | SEYMOUR
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37865-5414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-453-0130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP1025
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------