Provider Demographics
NPI:1386157881
Name:STREET, RICO D (LMSW)
Entity type:Individual
Prefix:
First Name:RICO
Middle Name:D
Last Name:STREET
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:MR
Other - First Name:RICO
Other - Middle Name:D
Other - Last Name:STREET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RICO STREET, LMSW
Mailing Address - Street 1:2220 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4315
Mailing Address - Country:US
Mailing Address - Phone:901-567-3554
Mailing Address - Fax:
Practice Address - Street 1:2220 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4315
Practice Address - Country:US
Practice Address - Phone:901-567-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM9136104100000X
TN11552104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker