Basic Information
| Provider Information | |||||||||
| NPI: | 1821129669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | FERNANDO | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 LINCOLN WAY E | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466013220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742322255 | ||||||||
| FaxNumber: | 5742328968 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N NAPPANEE ST STE 4A | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745228992 | ||||||||
| FaxNumber: | 5742328968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/10/2009 | ||||||||
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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 | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.