Provider Demographics
NPI:1538677521
Name:RICKETTS, ELIZABETH RENEE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RENEE
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EDGARTOWN VINEYARD HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-5699
Mailing Address - Country:US
Mailing Address - Phone:508-684-8126
Mailing Address - Fax:508-696-0401
Practice Address - Street 1:111 EDGARTOWN VINEYARD HAVEN RD
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-5699
Practice Address - Country:US
Practice Address - Phone:508-684-8126
Practice Address - Fax:508-696-0401
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 171M00000X, 175T00000X
MACHW1361172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACHW01361OtherCOMMUNITY HEALTH WORKER