Basic Information
| Provider Information | |||||||||
| NPI: | 1154766608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKABY | ||||||||
| FirstName: | TERI | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRUETT | ||||||||
| OtherFirstName: | TERI | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | LLMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 812 E JOLLY RD STE 311 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489106825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468200 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Practice Location | |||||||||
| Address1: | 566 N CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488541033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176762461 | ||||||||
| FaxNumber: | 5176763265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2013 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | H02073537 | 01 | MI | HEALTHPLUS | OTHER |