Provider Demographics
NPI:1245708122
Name:RICKETTS, TANEA L (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:TANEA
Middle Name:L
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 VETERANS AVE
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-3317
Mailing Address - Country:US
Mailing Address - Phone:618-704-1677
Mailing Address - Fax:618-551-4525
Practice Address - Street 1:1616 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-3317
Practice Address - Country:US
Practice Address - Phone:618-339-1063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017005989103K00000X
1-21-56513103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017005989OtherLBA