Basic Information
| Provider Information | |||||||||
| NPI: | 1700352713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKERT | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4124 SE BAVARIAN LN | ||||||||
| Address2: | |||||||||
| City: | OLALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983599435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532250057 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9601 BUJACICH RD NW | ||||||||
| Address2: | |||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983328300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538584200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2018 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60548226 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.