Healthcare Provider Details

I. General information

NPI: 1427248889
Provider Name (Legal Business Name): WALTER BRUCE RICKETTS MHRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 1ST ST
GILROY CA
95020-4733
US

IV. Provider business mailing address

1215 1ST ST
GILROY CA
95020-4733
US

V. Phone/Fax

Practice location:
  • Phone: 408-686-2371
  • Fax: 498-848-4370
Mailing address:
  • Phone: 408-686-2371
  • Fax: 498-848-4370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: