Provider Demographics
NPI:1902543044
Name:RICHARDSON, KEENA TISHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:KEENA
Middle Name:TISHELLE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 W COUNTY ROAD 125 S
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-8360
Mailing Address - Country:US
Mailing Address - Phone:432-413-7386
Mailing Address - Fax:
Practice Address - Street 1:1140 INDIANAPOLIS RD
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1458
Practice Address - Country:US
Practice Address - Phone:765-848-1421
Practice Address - Fax:765-301-4351
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006462A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant