Healthcare Provider Details

I. General information

NPI: 1881994572
Provider Name (Legal Business Name): MICA NICOLE RICKMAN MA,EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 NEW HOPE DR
CORINTH MS
38834-7458
US

IV. Provider business mailing address

401 NEW HOPE DR
CORINTH MS
38834-7458
US

V. Phone/Fax

Practice location:
  • Phone: 662-286-7199
  • Fax: 662-286-8908
Mailing address:
  • Phone: 662-286-7199
  • Fax: 662-286-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2760
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2654
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1772
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: