Provider Demographics
NPI:1548279235
Name:RICHARDSON, MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20347 TIMBERLAKE RD
Mailing Address - Street 2:STE B
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7352
Mailing Address - Country:US
Mailing Address - Phone:434-845-9053
Mailing Address - Fax:434-528-2788
Practice Address - Street 1:1111 CORPORATE PARK DR
Practice Address - Street 2:STE B
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-2286
Practice Address - Country:US
Practice Address - Phone:434-525-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8921822Medicaid
VA650016461Medicare ID - Type UnspecifiedMEDICARE RAILROAD
VA8921822Medicaid