Provider Demographics
NPI:1942500079
Name:RICKETTS, TONYA
Entity Type:Individual
Prefix:MS
First Name:TONYA
Middle Name:
Last Name:RICKETTS
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 1:650 W 177TH ST.
Mailing Address - Street 2:APT 51
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 CENTRAL AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033
Practice Address - Country:US
Practice Address - Phone:516-374-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPROVISIONAL LICENSE1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical