Provider Demographics
NPI:1043037757
Name:RICHARDSON, PRESLEY M (DCN)
Entity type:Individual
Prefix:DR
First Name:PRESLEY
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HOME CT
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4458
Mailing Address - Country:US
Mailing Address - Phone:310-780-2317
Mailing Address - Fax:
Practice Address - Street 1:107 OSBORNE ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6016
Practice Address - Country:US
Practice Address - Phone:203-792-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2707133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered