Basic Information
| Provider Information | |||||||||
| NPI: | 1457932105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKETTS | ||||||||
| FirstName: | THIESHA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746721 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 3129290373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 E 95TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606174708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737684437 | ||||||||
| FaxNumber: | 7735643515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2021 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1490223065 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.