Individual
MRS. STACEY RICHARDSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DTA
Contact information
Practice address
17736 SYCAMORE AVE, COUNTRY CLUB HILLS, IL 60478-4870
(708) 408-1320
Mailing address
17736 SYCAMORE AVE, COUNTRY CLUB HILLS, IL 60478-4870
(708) 408-1320
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
SR39520701A
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
SR39520701A
DTA CREDENTIAL
IL
Enumeration date
05/19/2007
Last updated
07/08/2007
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