Provider Demographics
NPI:1487908869
Name:RICKEY, KATHERINE K
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:K
Last Name:RICKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 LANDER RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5712
Mailing Address - Country:US
Mailing Address - Phone:216-831-2255
Mailing Address - Fax:
Practice Address - Street 1:347 MIDWAY BLVD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-9006
Practice Address - Country:US
Practice Address - Phone:440-324-4980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1200302-TRNE104100000X
OHS.13026891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid