Provider Demographics
NPI:1255197604
Name:ICKES, KARA ROSE
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:ROSE
Last Name:ICKES
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 1:402 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3112
Mailing Address - Country:US
Mailing Address - Phone:910-875-5590
Mailing Address - Fax:910-875-5008
Practice Address - Street 1:402 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3112
Practice Address - Country:US
Practice Address - Phone:910-875-5590
Practice Address - Fax:910-875-5008
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDP0202441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical