Provider Demographics
NPI:1346495231
Name:RICKS-BOUKNIGHT, STACEY LYNETTE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNETTE
Last Name:RICKS-BOUKNIGHT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:674 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-2231
Mailing Address - Country:US
Mailing Address - Phone:516-312-3654
Mailing Address - Fax:
Practice Address - Street 1:674 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-2231
Practice Address - Country:US
Practice Address - Phone:516-312-3654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070009-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker