MEDICARE: ILENE ANN RICHARDSON LCPC

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	101YP2500X	Professional Counselor	LC1278	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	412815000	OTHER	MD	STATE OF MARYLAND
2	805688000	OTHER	MD	MAGELLAN
3	7452697	OTHER	MD	AETNA

General Provider Information

NPI Number	:	1427044296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILENE ANN RICHARDSON LCPC

Provider Business Mailing Address
First Line	:	15262 RUSSELL DR
Second Line	:
City	:	ONANCOCK
State	:	VA
Zip	:	23417-3004
Country	:	US
Telephone Number	:	410-713-0709
Fax Number	:	410-546-0264

Provider Business Practice Location Address
First Line	:	15262 RUSSELL DR
Second Line	:
City	:	ONANCOCK
State	:	VA
Zip	:	23417-3004
Country	:	US
Telephone Number	:	410-713-0709
Fax Number	:	410-546-0264

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	01/10/2016

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Directions to “ ILENE ANN RICHARDSON LCPC” Practice Location

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