Provider Demographics
NPI:1699597567
Name:GAINES, RICKIESHA M
Entity type:Individual
Prefix:
First Name:RICKIESHA
Middle Name:M
Last Name:GAINES
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 1:4901 KINSEY DR APT 1924
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3036
Mailing Address - Country:US
Mailing Address - Phone:469-961-0379
Mailing Address - Fax:
Practice Address - Street 1:4901 KINSEY DR APT 1924
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3036
Practice Address - Country:US
Practice Address - Phone:469-961-0379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician