Provider Demographics
NPI:1659554905
Name:RICKETTS, STACEY CUPKA
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:CUPKA
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 1:1110 SW SCOTT DR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-8405
Mailing Address - Country:US
Mailing Address - Phone:863-494-5055
Mailing Address - Fax:863-494-5055
Practice Address - Street 1:1110 SW SCOTT DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8405
Practice Address - Country:US
Practice Address - Phone:863-494-5055
Practice Address - Fax:863-494-5055
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities