Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 031313 | GA |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 31313 | GA |
NPI | 1013006584 |
---|---|
Provider Name | Tommie M Richardson |
First Address | Smyrna, GA 30080 |
Second Address | Smyrna, GA 30080 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 16/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000471479F | (05) | GA |
B03010 | (02) |