Basic Information
| Provider Information | |||||||||
| NPI: | 1881835023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TODD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | RICHARDSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 MILFORD STREET | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218046966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105438291 | ||||||||
| FaxNumber: | 4103416275 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 MILFORD STREET | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218046966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105438291 | ||||||||
| FaxNumber: | 4103416275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2009 | ||||||||
| LastUpdateDate: | 03/18/2009 | ||||||||
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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 | 103TB0200X | 2756 | MD | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 2756 | MD | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 2756 | MD | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 64221800 | 05 | MD | MEDICAID |