=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487216107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CIARA DANIELLE RICKERT LCSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2019
-----------------------------------------------------
Last Update Date | 07/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2309 W CONE BLVD STE 150A
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-4066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-701-0267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 TREY LN
-----------------------------------------------------
City | ARCHDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27263-9435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-847-7405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P013623
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------