=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922691443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER RICHARDS CONDITIONAL LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2021
-----------------------------------------------------
Last Update Date | 02/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 PRESUMPSCOT ST UNIT 9
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04103-5299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-871-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 RICKER PARK APT A3
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-1617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-712-6391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | XL5667
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------