Provider Demographics
NPI:1134522337
Name:RICHARD, SHALETHA L
Entity type:Individual
Prefix:
First Name:SHALETHA
Middle Name:L
Last Name:RICHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHALETHA
Other - Middle Name:LASHAWN
Other - Last Name:RICHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:169 LAURELHURST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-3825
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:
Practice Address - Street 1:1228 HARDEN ST STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1800
Practice Address - Country:US
Practice Address - Phone:803-722-1565
Practice Address - Fax:803-888-1771
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9433101YP2500X
OKJ082698428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health