Basic Information
| Provider Information | |||||||||
| NPI: | 1578843363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CASEMANAGER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 191 JORALEMON ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187226000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 249 CLASSON AVE | ||||||||
| Address2: | MERCY GARDENS | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112051440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183998141 | ||||||||
| FaxNumber: | 7183993208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.