Healthcare Provider Details

I. General information

NPI: 1003307216
Provider Name (Legal Business Name): ALEXA MARIE RICKERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 STEWART AVE STE 408
GARDEN CITY NY
11530-4701
US

IV. Provider business mailing address

250 HARRISON AVE
MINEOLA NY
11501-3943
US

V. Phone/Fax

Practice location:
  • Phone: 516-280-7285
  • Fax:
Mailing address:
  • Phone: 973-865-9269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP05237
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: