Basic Information
Provider Information | |||||||||
NPI: | 1952541872 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDSON | ||||||||
FirstName: | CARMELA | ||||||||
MiddleName: | ALTAMSES | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LLMSW,LPN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2900 CONNER ST | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482152407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133081400 | ||||||||
FaxNumber: | 3133081600 | ||||||||
Practice Location | |||||||||
Address1: | 25127 LINDENWOOD LN | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480336189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162158522 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2009 | ||||||||
LastUpdateDate: | 12/09/2014 | ||||||||
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 | 164W00000X | 4703112909 | MI | N |   | Nursing Service Providers | Licensed Practical Nurse |   | 1041C0700X | 6801094881 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | S.0701223 | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker |   | 164W00000X | PN.091680 | OH | N |   | Nursing Service Providers | Licensed Practical Nurse |   |
No ID Information.