Provider Demographics
NPI:1568474450
Name:RICKLIS, PEARL B (LCSW)
Entity type:Individual
Prefix:
First Name:PEARL
Middle Name:B
Last Name:RICKLIS
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 1:199 SCOLES AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1125
Mailing Address - Country:US
Mailing Address - Phone:973-777-7638
Mailing Address - Fax:973-777-9311
Practice Address - Street 1:199 SCOLES AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1125
Practice Address - Country:US
Practice Address - Phone:973-777-7638
Practice Address - Fax:973-777-9311
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC013103001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021784Medicaid
NJ072145OtherVALUE OPTION ID
NJ270260OtherMHN ID
NJ7286582OtherAETNA
NJ7482682OtherGHI ID
NJP-841937OtherOXFORD
NJ760739CV4Medicare ID - Type UnspecifiedMEDICARE ID