Healthcare Provider Details

I. General information

NPI: 1033367719
Provider Name (Legal Business Name): HALLE RICKETTS MSW LICSW/LCSW LSSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N LYNCH ST
GRENADA MS
38901-2004
US

IV. Provider business mailing address

121 N LYNCH ST
GRENADA MS
38901-2004
US

V. Phone/Fax

Practice location:
  • Phone: 601-226-0284
  • Fax:
Mailing address:
  • Phone: 601-226-0284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14301
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC6249
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number383604
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: