Basic Information
Provider Information | |||||||||
NPI: | 1962539387 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDSON | ||||||||
FirstName: | AVORY | ||||||||
MiddleName: | MCWILLIAMS | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BS, MSCE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RICHARDSON | ||||||||
OtherFirstName: | AVORY | ||||||||
OtherMiddleName: | MCWILLIAMS | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 5750A SOUTHLAND DR | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366933316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516627317 | ||||||||
FaxNumber: | 2516627297 | ||||||||
Practice Location | |||||||||
Address1: | 5750A SOUTHLAND DR | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366933316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516627317 | ||||||||
FaxNumber: | 2516627297 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2007 | ||||||||
LastUpdateDate: | 02/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YP2500X | 4026 | AL | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 00018214 | 05 | MS |   | MEDICAID |