Provider Demographics
NPI:1427248889
Name:RICKETTS, WALTER BRUCE (MHRS)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:BRUCE
Last Name:RICKETTS
Suffix:
Gender:M
Credentials:MHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4733
Mailing Address - Country:US
Mailing Address - Phone:408-686-2371
Mailing Address - Fax:498-848-4370
Practice Address - Street 1:1215 1ST ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4733
Practice Address - Country:US
Practice Address - Phone:408-686-2371
Practice Address - Fax:498-848-4370
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health