MEDICARE: MARY RICHARDSON

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1538595376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY RICHARDSON

Provider Business Mailing Address
First Line	:	2708 NE 14TH ST
Second Line	:	SUITE 5
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-3565
Country	:	US
Telephone Number	:	888-880-9270
Fax Number	:

Provider Business Practice Location Address
First Line	:	7906 BAYONET CIR APT C
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80902
Country	:	US
Telephone Number	:	803-402-2041
Fax Number	:

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

Provider Enumeration Date	:	09/25/2013
Last Update Date	:	02/21/2019

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