Provider Demographics
NPI:1538751730
Name:RICKETT, SAM
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:RICKETT
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 1:21139 LORAIN RD STE 12
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2149
Mailing Address - Country:US
Mailing Address - Phone:330-529-5667
Mailing Address - Fax:
Practice Address - Street 1:21139 LORAIN RD STE 12
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2149
Practice Address - Country:US
Practice Address - Phone:330-529-5667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2001605-TRNE1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical