MEDICARE: RONALD G. RICKNER, PH.D.

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	103TC0700X	Clinical Psychologist	PY0005144	FL

General Provider Information

NPI Number	:	1801207345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RONALD G. RICKNER, PH.D.

Provider Business Mailing Address
First Line	:	1535 KILLEARN CENTER BLVD
Second Line	:	SUITE C-2
City	:	TALLAHASSEE
State	:	FL
Zip	:	32309-3467
Country	:	US
Telephone Number	:	850-668-0482
Fax Number	:	850-894-9957

Provider Business Practice Location Address
First Line	:	1535 KILLEARN CENTER BLVD
Second Line	:	SUITE C-2
City	:	TALLAHASSEE
State	:	FL
Zip	:	32309-3467
Country	:	US
Telephone Number	:	850-668-0482
Fax Number	:	850-894-9957

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. RONALD G. RICKNER
Credential	:	PH.D.
Telephone Number	:	850-668-0482

Provider Enumeration Date	:	05/19/2014
Last Update Date	:	05/19/2014

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