| Doctor Name: | RYAN KEITH ICKES |
| NPI Number: | 1447540497 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | 0904007624 |
| Business Practice Address: | 9101 Washington Street Amelia, VA - 23002 |
| Business Phone Number: | 8045615057 |
| Business Fax Number: | 4343929221 |
| Mailing Address: | Po Box 293, AMELIA |
| State: | VA |
| Postal Code: | 23002 |
| Phone Number: | 8045615057 |
| Fax Number: | 4343929221 |
| NPI Enumeration Date: | 04/12/2011 |
| NPI Last Update Date: | 04/12/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 0904007624 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |