MEDICARE: RICKETTA TIARA ARLINE M, E.D.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1649730219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICKETTA TIARA ARLINE M, E.D.

Provider Business Mailing Address
First Line	:	260 S MARION AVE STE 105
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-7034
Country	:	US
Telephone Number	:	800-817-5404
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 S MARION AVE STE 105
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-7034
Country	:	US
Telephone Number	:	800-817-5404
Fax Number	:	904-775-3570

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

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	03/21/2019

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