MEDICARE: ISAIAH SAGE RICHARDS MSW

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1417782715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISAIAH SAGE RICHARDS MSW

Provider Business Mailing Address
First Line	:	5860 BAKER RD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5903
Country	:	US
Telephone Number	:	952-767-4200
Fax Number	:	952-767-4211

Provider Business Practice Location Address
First Line	:	3380 NORTHERN VALLEY PL NE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55906-3954
Country	:	US
Telephone Number	:	952-767-4200
Fax Number	:	952-767-4211

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

Provider Enumeration Date	:	09/05/2024
Last Update Date	:	09/05/2024

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