Ryan Keith Ickes, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

0904007624 Issued in VA

Practice address

5201 Great America Pkwy Ste 320
Santa Clara, CA 95054-1140

Phone

(323) 205-7088

Fax

(833) 419-0181

NPI assigned

Apr 12, 2011

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Crossroads Services Board

  • Community/Behavioral Health Agency
  • Farmville, VA
  • NPI 1528091063

  Clinical

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1302566400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1716940800000",
    "number": "1447540497",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13313 DIAMOND RIDGE DR",
            "city": "MIDLOTHIAN",
            "state": "VA",
            "postal_code": "231128340",
            "telephone_number": "804-615-0421"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5201 GREAT AMERICA PKWY STE 320",
            "city": "SANTA CLARA",
            "state": "CA",
            "postal_code": "950541140",
            "telephone_number": "323-205-7088",
            "fax_number": "833-419-0181"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ICKES",
        "first_name": "RYAN",
        "middle_name": "KEITH",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-04-12",
        "last_updated": "2024-05-29",
        "certification_date": "2024-05-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "CA",
            "license": "122497",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "VA",
            "license": "0904007624",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Alex Im, MD

• Clinical Social Worker in Santa Clara, CA
• Providers in Santa Clara, CA by specialty
• Clinical Social Worker in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.