Provider Demographics
NPI:1053139485
Name:RICHARDSON, MYRA LYNN (RBT)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1667
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-1667
Mailing Address - Country:US
Mailing Address - Phone:843-628-2935
Mailing Address - Fax:
Practice Address - Street 1:222 RED BANK RD
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-4502
Practice Address - Country:US
Practice Address - Phone:843-628-2935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-24-324366106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician