Provider Demographics
NPI:1760655823
Name:RICCO, ROBERT JOHN (MS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:RICCO
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-0160
Mailing Address - Country:US
Mailing Address - Phone:304-624-6554
Mailing Address - Fax:304-624-5223
Practice Address - Street 1:82 UTT DRIVE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354
Practice Address - Country:US
Practice Address - Phone:304-624-6554
Practice Address - Fax:304-624-5223
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10026103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165937000Medicaid