Provider Demographics
NPI:1104982123
Name:RALICKI, JEANNE PRESCOTT (LCSW)
Entity type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:PRESCOTT
Last Name:RALICKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2025
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-2025
Mailing Address - Country:US
Mailing Address - Phone:772-220-1629
Mailing Address - Fax:772-221-4509
Practice Address - Street 1:1541 SE PALM CT
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4914
Practice Address - Country:US
Practice Address - Phone:772-220-1629
Practice Address - Fax:772-221-4509
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW26241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3457OtherBC-BS OF FL
FL11403842OtherCAQH
FL11403842OtherCAQH