Provider Demographics
NPI:1689417040
Name:RICHARDSON, CHARLES PAUL JR
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PAUL
Last Name:RICHARDSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6110 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2009
Mailing Address - Country:US
Mailing Address - Phone:916-642-7800
Mailing Address - Fax:888-870-9642
Practice Address - Street 1:6110 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2009
Practice Address - Country:US
Practice Address - Phone:916-642-7800
Practice Address - Fax:888-870-9642
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes172V00000XOther Service ProvidersCommunity Health Worker