Provider Demographics
NPI:1033367719
Name:RICKETTS, HALLE (MSW LICSW/LCSW LSSW)
Entity Type:Individual
Prefix:MR
First Name:HALLE
Middle Name:
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:MSW LICSW/LCSW LSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N LYNCH ST
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-2004
Mailing Address - Country:US
Mailing Address - Phone:601-226-0284
Mailing Address - Fax:
Practice Address - Street 1:121 N LYNCH ST
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-2004
Practice Address - Country:US
Practice Address - Phone:601-226-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN143011041C0700X
MSC62491041C0700X
MN3836041041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN149722700Medicaid