Provider Demographics
NPI:1548549173
Name:RICHARDSON, VANAVIA NAOMI (MBA)
Entity type:Individual
Prefix:
First Name:VANAVIA
Middle Name:NAOMI
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 FORUM PARK DR
Mailing Address - Street 2:STE 920
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-8238
Mailing Address - Country:US
Mailing Address - Phone:832-775-5203
Mailing Address - Fax:713-431-5245
Practice Address - Street 1:5202 CEDAR ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3915
Practice Address - Country:US
Practice Address - Phone:832-775-5203
Practice Address - Fax:713-431-4524
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-13
Last Update Date:2011-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13315101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189407301Medicaid