Provider Demographics
NPI:1952324469
Name:RICKETTS, ROBERTA T (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:T
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 SW 5TH AVE
Mailing Address - Street 2:SUITE 725
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2133
Mailing Address - Country:US
Mailing Address - Phone:503-222-2448
Mailing Address - Fax:503-222-2395
Practice Address - Street 1:522 SW 5TH AVE
Practice Address - Street 2:SUITE 725
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2133
Practice Address - Country:US
Practice Address - Phone:503-222-2448
Practice Address - Fax:503-222-2395
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1427103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
J930714OtherPACIFIC SOURCE