Basic Information
| Provider Information | |||||||||
| NPI: | 1083885438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKS | ||||||||
| FirstName: | SHIKOLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 E DAKOTA AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937044374 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 114 E SHAW AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937107621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592218100 | ||||||||
| FaxNumber: | 5592218101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 03/13/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 101076 | 01 | CA | MEDI-CAL | OTHER |