Provider Demographics
NPI:1043786387
Name:RICKLES, LAURA JACK
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JACK
Last Name:RICKLES
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 1:7700 RENFREW LN
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-3508
Mailing Address - Country:US
Mailing Address - Phone:850-212-7757
Mailing Address - Fax:
Practice Address - Street 1:7700 RENFREW LN
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-3508
Practice Address - Country:US
Practice Address - Phone:850-212-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2897221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist