Provider Demographics
NPI:1679720353
Name:RICHARDSON, WANDA M IV (LMSW)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:M
Last Name:RICHARDSON
Suffix:IV
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 BAY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2503
Mailing Address - Country:US
Mailing Address - Phone:718-981-7861
Mailing Address - Fax:718-981-6852
Practice Address - Street 1:148 BAY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2503
Practice Address - Country:US
Practice Address - Phone:718-981-7861
Practice Address - Fax:718-981-6852
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070041171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator