Provider Demographics
NPI:1053381087
Name:RICHARDSON, ELLEN Q (MA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:Q
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 E KINGSLEY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7216
Mailing Address - Country:US
Mailing Address - Phone:417-882-4110
Mailing Address - Fax:417-882-4155
Practice Address - Street 1:1320 E KINGSLEY ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7216
Practice Address - Country:US
Practice Address - Phone:417-882-4110
Practice Address - Fax:417-882-4155
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01083103TC0700X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent