MEDICARE: PATRICIA S RICKENBAKER LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C002420	NC

General Provider Information

NPI Number	:	1154387470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA S RICKENBAKER LISW

Provider Business Mailing Address
First Line	:	4601 LAKE BOONE TRL
Second Line	:	SUITE 2-C
City	:	RALEIGH
State	:	NC
Zip	:	27607-7503
Country	:	US
Telephone Number	:	919-539-9650
Fax Number	:	919-787-6470

Provider Business Practice Location Address
First Line	:	4601 LAKE BOONE TRL
Second Line	:	SUITE 2-C
City	:	RALEIGH
State	:	NC
Zip	:	27607-7503
Country	:	US
Telephone Number	:	919-539-9650
Fax Number	:	919-787-6470

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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