Basic Information
Provider Information | |||||||||
NPI: | 1598914335 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDSON | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BSN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 250 DEWEY AVE | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293033009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645850366 | ||||||||
FaxNumber: | 8645850362 | ||||||||
Practice Location | |||||||||
Address1: | 250 DEWEY AVE | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293033009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645850366 | ||||||||
FaxNumber: | 8645850362 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2008 | ||||||||
LastUpdateDate: | 09/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 55661 | SC | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1427168889 | 05 | SC |   | MEDICAID |