Provider Demographics
NPI:1821585191
Name:RICKS, IMANI
Entity Type:Individual
Prefix:MS
First Name:IMANI
Middle Name:
Last Name:RICKS
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 1:7925 VININGS OAK LN APT 532
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5119
Mailing Address - Country:US
Mailing Address - Phone:336-416-9266
Mailing Address - Fax:
Practice Address - Street 1:3409 W WENDOVER AVE STE I
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1579
Practice Address - Country:US
Practice Address - Phone:336-652-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-22
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NCP0114011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker