Provider Demographics
NPI:1659776201
Name:RICO, KEITH JAMES (LBA, BCBA, LMHC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:RICO
Suffix:
Gender:M
Credentials:LBA, BCBA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 OLD ROUTE 17
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-7013
Mailing Address - Country:US
Mailing Address - Phone:845-707-8442
Mailing Address - Fax:
Practice Address - Street 1:606 OLD ROUTE 17
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7013
Practice Address - Country:US
Practice Address - Phone:845-707-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005193101YM0800X
NY000045103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health