Provider Demographics
NPI:1003307216
Name:RICKERT, ALEXA MARIE
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:MARIE
Last Name:RICKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3943
Mailing Address - Country:US
Mailing Address - Phone:973-865-9269
Mailing Address - Fax:
Practice Address - Street 1:585 STEWART AVE STE 408
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4701
Practice Address - Country:US
Practice Address - Phone:516-280-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP05237101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health