MEDICARE: TRESA HARRIS RICHARDSON MSW, LCSW, ACSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	001081	MO
2	1041C0700X	Clinical Social Worker	149.012904	IL

General Provider Information

NPI Number	:	1023305166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRESA HARRIS RICHARDSON MSW, LCSW, ACSW

Provider Business Mailing Address
First Line	:	12496 OLD 79
Second Line	:
City	:	NEW LONDON
State	:	MO
Zip	:	63459-2741
Country	:	US
Telephone Number	:	573-248-2051
Fax Number	:	573-248-2051

Provider Business Practice Location Address
First Line	:	12496 OLD 79
Second Line	:
City	:	NEW LONDON
State	:	MO
Zip	:	63459-2741
Country	:	US
Telephone Number	:	573-248-2051
Fax Number	:	573-248-2051

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2011
Last Update Date	:	07/08/2011

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