Provider Demographics
NPI:1568680452
Name:RICCI, ANTHONY MICHAEL (PHD)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:RICCI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5085 LIST DR STE 110
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3313
Mailing Address - Country:US
Mailing Address - Phone:719-594-4407
Mailing Address - Fax:719-594-4409
Practice Address - Street 1:5085 LIST DR STE 110
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3313
Practice Address - Country:US
Practice Address - Phone:719-594-4407
Practice Address - Fax:719-594-4409
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO416103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA0516Medicare ID - Type Unspecified