Provider Demographics
NPI:1225300692
Name:RICHARDSON, WAYNE B
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:B
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3120 E ANITA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-3905
Mailing Address - Country:US
Mailing Address - Phone:209-415-0315
Mailing Address - Fax:
Practice Address - Street 1:503 S PERSHING AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3236
Practice Address - Country:US
Practice Address - Phone:209-810-5864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility