Provider Demographics
NPI:1104241470
Name:RICO, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:RICO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8323 ARTSON ST
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-2611
Mailing Address - Country:US
Mailing Address - Phone:626-378-4288
Mailing Address - Fax:
Practice Address - Street 1:1160 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5000
Practice Address - Country:US
Practice Address - Phone:626-335-5980
Practice Address - Fax:626-335-5989
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW76002101YM0800X
390200000X
CA1001771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program