Basic Information
Provider Information | |||||||||
NPI: | 1952619249 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDSON | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | RUSSELL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | I | ||||||||
Credential: | AAEE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RICHARDSON | ||||||||
OtherFirstName: | STEVE | ||||||||
OtherMiddleName: | RUSSELL | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: | I | ||||||||
OtherCredential: | AAEE | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2046 NW FLANDERS ST | ||||||||
Address2: | 21 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972091159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5038042520 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1312 SW WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972052327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5035351150 | ||||||||
FaxNumber: | 5035351191 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2010 | ||||||||
LastUpdateDate: | 09/20/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.