MEDICARE: MS. IMANI RICKS

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
2	1041C0700X	Clinical Social Worker	P011401	NC

General Provider Information

NPI Number	:	1821585191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. IMANI RICKS

Provider Business Mailing Address
First Line	:	7925 VININGS OAK LN APT 532
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-5119
Country	:	US
Telephone Number	:	336-416-9266
Fax Number	:

Provider Business Practice Location Address
First Line	:	3409 W WENDOVER AVE STE I
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-1579
Country	:	US
Telephone Number	:	336-652-3638
Fax Number	:

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

Provider Enumeration Date	:	04/22/2018
Last Update Date	:	08/16/2019

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Directions to “ MS. IMANI RICKS ” Practice Location

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