Provider Demographics
NPI:1235019811
Name:RICHARDSON, REBECCA DIANE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:DIANE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 OUTRIGGER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-8058
Mailing Address - Country:US
Mailing Address - Phone:803-504-1023
Mailing Address - Fax:
Practice Address - Street 1:2144 SUMTER ST STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2182
Practice Address - Country:US
Practice Address - Phone:803-258-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25-446135106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty