Healthcare Provider Details

I. General information

NPI: 1336739622
Provider Name (Legal Business Name): ROBERT B RICKLE JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2039 COTTAGE SAN RD
SILVER CITY NM
88061-8968
US

IV. Provider business mailing address

415 W MICHIGAN ST
SILVER CITY NM
88061-4644
US

V. Phone/Fax

Practice location:
  • Phone: 575-956-8698
  • Fax:
Mailing address:
  • Phone: 575-956-8698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10925
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: