Provider Demographics
NPI:1053397471
Name:RICKETTS, PERCIVAL GEORGE (EDD, LMHC)
Entity type:Individual
Prefix:DR
First Name:PERCIVAL
Middle Name:GEORGE
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:EDD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10031 PINES BLVD
Mailing Address - Street 2:#242
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6179
Mailing Address - Country:US
Mailing Address - Phone:954-438-5661
Mailing Address - Fax:
Practice Address - Street 1:10031 PINES BLVD
Practice Address - Street 2:#242
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6179
Practice Address - Country:US
Practice Address - Phone:954-438-5661
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6153101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH6153OtherSTATE LICENCE NUMBER