Provider Demographics
NPI:1225369689
Name:RICKMAN, FRED (LCSW)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:RICKMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1995
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-1995
Mailing Address - Country:US
Mailing Address - Phone:601-695-1919
Mailing Address - Fax:601-420-5299
Practice Address - Street 1:254 INGLESIDE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-9524
Practice Address - Country:US
Practice Address - Phone:601-695-1919
Practice Address - Fax:601-420-5299
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical