Provider Demographics
NPI:1629551445
Name:RICKERT, CHRYSTIN LENORE
Entity Type:Individual
Prefix:
First Name:CHRYSTIN
Middle Name:LENORE
Last Name:RICKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7410 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5612
Mailing Address - Country:US
Mailing Address - Phone:330-770-7274
Mailing Address - Fax:
Practice Address - Street 1:111 STADIUM DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5521
Practice Address - Country:US
Practice Address - Phone:330-726-3428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.11781235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist