Provider Demographics
NPI:1447989546
Name:RICHARD, MARY CHRISTINE
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CHRISTINE
Last Name:RICHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:CHRISTINE
Other - Last Name:DURHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 N MIDVALE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3265
Mailing Address - Country:US
Mailing Address - Phone:608-238-9991
Mailing Address - Fax:608-238-1929
Practice Address - Street 1:3058 SADDLE BROOKE TRL
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-9394
Practice Address - Country:US
Practice Address - Phone:608-571-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3001021727101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool