MEDICARE: RICO D STREET LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	M9136	MS
2	104100000X	Social Worker	11552	TN

General Provider Information

NPI Number	:	1386157881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICO D STREET LMSW

Provider Business Mailing Address
First Line	:	2220 UNION AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38104-4315
Country	:	US
Telephone Number	:	901-567-3554
Fax Number	:

Provider Business Practice Location Address
First Line	:	2220 UNION AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38104-4315
Country	:	US
Telephone Number	:	901-567-3554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	11/07/2017

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Directions to “ RICO D STREET LMSW” Practice Location

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