Provider Demographics
NPI:1609346402
Name:RICHARDSON, DOUGLASS (MSPSY, CADC III)
Entity type:Individual
Prefix:MR
First Name:DOUGLASS
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:
Credentials:MSPSY, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12935 ALCOSTA BLVD UNIT 3882
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-6181
Mailing Address - Country:US
Mailing Address - Phone:209-696-1125
Mailing Address - Fax:
Practice Address - Street 1:620 N AURORA ST STE 1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2276
Practice Address - Country:US
Practice Address - Phone:209-468-9370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABII00640223172V00000X, 101YA0400X, 373H00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)