Provider Demographics
NPI:1578862108
Name:RICKS, DEIDRE ANN (MFT)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:ANN
Last Name:RICKS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:DEIDRE
Other - Middle Name:ANN
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:1094 CUDAHY PL STE 314
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3924
Mailing Address - Country:US
Mailing Address - Phone:619-276-8812
Mailing Address - Fax:619-276-8230
Practice Address - Street 1:1094 CUDAHY PL STE 314
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3924
Practice Address - Country:US
Practice Address - Phone:619-276-8812
Practice Address - Fax:619-276-8230
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40522106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist