Provider Demographics
NPI:1831170018
Name:RIKSHEIM, MARY ANN (MSW)
Entity type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:
Last Name:RIKSHEIM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 LINCOLN HWY
Mailing Address - Street 2:SUITE 14B
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1627
Mailing Address - Country:US
Mailing Address - Phone:708-748-8309
Mailing Address - Fax:708-748-8351
Practice Address - Street 1:3612 LINCOLN HWY
Practice Address - Street 2:SUITE 14B
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1627
Practice Address - Country:US
Practice Address - Phone:708-748-8309
Practice Address - Fax:708-748-8309
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0025861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL574130Medicare PIN