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General NPI Number Information
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NPI Number | 1912171828
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Entity Type | Organization
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Legal Business Name | FRED LEE RICHARDSON
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 625 CLAY
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City | KERRVILLE
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State | TX
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Zip | 78028-4586
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Country | US
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Telephone | 830-792-3900
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 134
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City | COMFORT
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State | TX
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Zip | 78013-1013
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Country | US
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Telephone | 830-792-3900
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. FRED LEE RICHARDSON
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Credential | MA,LPC,LCDC,LM&FT
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Telephone | 830-792-3900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 9502
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License Number State | TX
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