=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750080974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA RENEE RICHARDSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 02/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 391 HERSHBERGER RD
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24012-1983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-265-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5647 STARKEY RD
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-9034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-777-8485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904014818
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------