Provider Demographics
NPI:1174655864
Name:RICKETTS, BRENDA CANTER (LICENSED PROFESSIONA)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:CANTER
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:LICENSED PROFESSIONA
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:C
Other - Last Name:RICKETTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSED PROFESSIONA
Mailing Address - Street 1:P.O. BOX 4261
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036
Mailing Address - Country:US
Mailing Address - Phone:704-608-9891
Mailing Address - Fax:
Practice Address - Street 1:725 PROVIDENCE RD.
Practice Address - Street 2:SUITE 302
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207
Practice Address - Country:US
Practice Address - Phone:704-608-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2830101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11023OtherBLUE CROSS BLUE SHIELD