Provider Demographics
NPI:1023681376
Name:RICKETTS, LANE BROOKS (OTR)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:BROOKS
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 EBENEZER CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:DE
Mailing Address - Zip Code:19734-9633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 SALLITT DR
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21666-2156
Practice Address - Country:US
Practice Address - Phone:443-249-3126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
452401OtherNBCOT CERTIFICATION NUMBER