Basic Information
| Provider Information | |||||||||
| NPI: | 1275682197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FICKARDT | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 SHADOWBROOK WAY #9 | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308775623 | ||||||||
| FaxNumber: | 5308956549 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 SHADOWBROOK WAY #9 | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308775623 | ||||||||
| FaxNumber: | 5308956549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YM0800X | 20409 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | ASW #20409 | 01 | CA | BOARD OF BEHAVIORAL SCIEN | OTHER |